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AMNESIA AND ANALGESIA 

IN PARTURITION 

(TWILIGHT SLEEP) 



AMNESIA AND ANALGESIA 

IN PARTURITION 

(TWILIGHT SLEEP) 

BY 
ALFRED M. HELLMAN, b.a, m.d., f.a.c.s. 

l\ 

ADJUNCT ATTENDING GYNECOLOGIST AND OBSTETRICIAN LEBANON 

HOSPITAL, ATTENDING GYNECOLOGIST GERMAN HOSPITAL 

DISPENSARY, FELLOW NEW YORK ACADEMY 

OF MEDICINE. ETC.. ETC. 




NEW YORK 

PAUL B. HOEBER 
1915 



*<0 



*> 

^ 



Copyright, 19 15, 
By Paul B. Hoeber 



Published July, IQ15 



/£2- 

Printed in the United States of America 

AUG 17 1915 
©C1.A410108 



AUTHOE'S NOTE 

It is a great pleasure to have this oppor- 
tunity to thank the German clinicians for 
their unfailing courtesy, and my attending 
physician, Dr. Gustav Seeligmann, for his 
kindness in allowing me to use the obstet- 
rical material at the Lebanon Hospital. I 
desire to express my appreciation to the 
authorities of that institution and to its 
house staff and nurses for their assistance. 
Special thanks are due to Mr. Paul B. 
Hoeber, at whose request this book was 
written, for his help and many suggestions. 

At /feed M. Hellman. 

2 West 86th Street, New York. 
June, 1915. 



INTRODUCTION 

This little monograph had its origin in 
the desire of many of the author's medical 
friends to obtain a clear conception of the 
much discussed "Twilight Sleep.' ' They 
seem to require a presentation of all the 
facts in one small book, as they have not 
the time to delve into the more than one 
hundred volumes that contain information 
on the subject. And this, the author under- 
stands from his publisher, is quite general 
among physicians. It is therefore hoped 
that this monograph will be useful to every 
physician whether he wishes to use Twi- 
light Sleep or simply desires to advise his 
patients as to its value ; for every medical 
man, no matter what his specialty, is over- 
whelmed with interrogations on this sub- 
ject. In almost every instance the author 
7 



8 INTRODUCTION 

has gone to the original article. He has 
given a review of the contributions of im- 
portance on both sides of the controversy. 
He has delved into the German, Austrian, 
Swiss, Polish, English, Eussian and 
French literature and has tried to give all 
the latest reports from Amerila, where 
most of the work is now being done. 

The subject is worthy of a thorough 
study on the part of the medical profession 
and only after such study has the profes- 
sion a right to reach a conclusion. How- 
ever the lay agitation may be regretted, 
physicians must not be led into an attitude 
of opposition until that opposition is based 
on scientific data. If the study of the sub- 
ject shows that Twilight Sleep is of greater 
or less value, then the profession must an- 
nounce that fact to a public that will, in 
the last analysis, look to the medical frater- 
nity for decision and advice. 

The recent lay agitation for the relief of 
the pains of labor has reawakened in the 



INTRODUCTION 9 

medical profession an acute interest in this 
subject and has led to the reporting of 
cases, experiences and opinions. All this 
emphasizes the fact that, ever since the in- 
troduction of ether in 1847, medical science 
has been steadily attempting to ameliorate 
these pains. Ether, chloroform, cocaine 
(local and intra spinous), opium, laudanum, 
chloral, antipyrine and other substances al- 
most without end have been tried and either 
discarded, or relegated to their proper 
places for use in a certain few selected 
cases. More recently most of the work has 
been done with heroin, antalgesine, mor- 
phine, and scopolamine (hyo seine) and 
more particularly with these last two in 
combination, in what is known as the Frei- 
burg method of Dammerschlaf (Twilight 
Sleep). Of course ether, chloroform, and 
even ethyl chloride still have their uses, 
with or without twilight sleep. 

The author will deal almost entirely with 
the Freiburg method and simply touch on 



10 INTBODUCTION 

its variations and the other methods now 
being recommended. For the present, and 
certainly for some time to come, the Frei- 
burg method will remain of most interest, 
and until its proper value for American 
obstetrics has been finally decided there 
will hardly be opportunity to experiment 
with the other methods that are being sug- 
gested in such rapid succession. To this 
literature have been added a few theoreti- 
cal considerations and a statistical report 
of sixty-six cases from the Lebanon Hos- 
pital. There are also added the result of a 
questionnaire answered by fifty American 
obstetricians and a bibliography of the ar- 
ticles used in making this volume, some 
references to closely allied subjects, and 
finally, there are four specimen charts used 
in conducting Twilight cases, which may be 
interesting as models. 



CONTENTS 

CHAPTER PAGE 

I. History of Scopolamine in Obstetrics 
with 4 a Review of Some of the Lit- 
erature 13 

II. The Freiburg Technique of Twilight 

Sleep 66 

III. Controversy Between Freiburg and Ber- 

lin 78 

IV. Chemistry and Pharmacology of Scop- 

olamine 86 

V. Further Review of the Literature, with 
Special Reference to Twilight Sleep 
in England 93 

VI. Twilight Sleep in America and Results 

of a Questionnaire 104 

VII. Some Theoretical Considerations of 

Twilight Sleep 128 

VIII. Case Reports with Statistics .... 133 

IX. Other Methods of Painless Childbirth 144 

X. Conclusions 156 

Specimen Charts 163 

Bibliography 175 

Index 191 



TWILIGHT SLEEP 



HISTORY OF SCOPOLAMINE IX OBSTETRICS WITH 

A REVIEW OF SOME OF THE LITERATURE 

The first mention of the use of scopo- 
lamine and morphine in obstetrics appears 
in an article by von Steinbnchel in the 
Centralblatt fiir Gynakologie, No. 45, 1902. 
In this article von Steinbnchel states that, 
stimulated by the work of KorfT in surgery 
and Schneiderlein in psychiatry, he de- 
cided to try out the analgesic effects of 
these drugs in labor. The next year, while 
he was docent for gynecology and obstet- 
rics in the University of Graz, he reported 
under the title. "Die Scopolamine Mor- 
phine Haibnarkose in der Geburtschilfe." 
the first twenty cases of labor in which 
these drugs were used in combination. 
13 



14 TWILIGHT SLEEP 

He obtained a diminution of pain bnt no 
anesthesia. He nsed very much smaller 
doses than had been tried in surgery. His 
greatest achievement was the inspiration 
he gave to others to make further experi- 
ments in obstetrics with this combination. 

In his original article he set forth, as the 
basic requirements of any treatment given 
with the object of helping the mother, the 
following principles : 

1. It must appreciably reduce the pain. 

2. It must not stop the uterine contrac- 
tions. 

3. It must not contra-indicate the use of 
general anesthesia. 

4. It must be safe for the mother. 

5. It must not harm the child. 

6. It must not cause post-partum atony 
of the uterus. 

In his second article, in which he re- 
ported the first twenty cases, he outlined 
his treatment. He gave the patients one 
or two injections, at intervals of at least 



TWILIGHT SLEEP 15 

two hours, of scopolamine 0.0003 (gr. 
1/200) and morphine 0.01 (gr. 1/6). He 
used his preparations in solution, freshly 
boiling each one separately, and later had 
the combination of the two drugs put up 
in ampules. Of the twenty cases, only one 
remained entirely unrelieved of her pain, 
three were only partially relieved. In 
twelve cases the contractions were undis- 
turbed. In two instances the intervals be- 
tween the pains were lessened. Six times 
the intervals were lengthened, but the 
duration of the contractions remained un- 
changed. He had three cases of atony of 
the uterus, but they had received chloro- 
form in addition to the other drugs. Vomit- 
ing was not increased. One nervous patient 
became excited for a short time. There 
were seven forceps cases, and two extrac- 
tions of the after-coming head in breech 
presentations. Three times he had to 
dilate the cervix manually. 

This is certainly a very high operative 



16 TWILIGHT SLEEP 

percentage, but von Steinbuchel claims 
that in no case was the operation necessi- 
tated by the use of scopolamine. One child 
was born asphyxiated after a protracted 
labor completed by forceps. There were 
two still-births, one a macerated fetus and 
the other a hydatidiform. Later von 
Steinbuchel reported eleven additional 
cases without any mishap. He came to the 
conclusion that the mothers were fre- 
quently robbed of the memory of events 
that transpired during the action of the 
drug. There was no lessening of the con- 
tractions, and no poisoning of the child. 
In other words, the six requirements that 
he had laid down in his preliminary article, 
before using these drugs, had been fulfilled. 
In 1904 Wartapetian, in his Inaugural 
Dissertation at Jena, reported his results 
in twenty cases. Certain of the cases re- 
ceived as many as five injections of scopol- 
amine 0.00033 (gr. 1/200) and morphine 
0.01 (gr. 1/6). Fifty per cent of the chil- 



TWILIGHT SLEEP 17 

dren were born dazed. He ascribed this to 
the large amount of morphine he had used. 
The intensity and frequency of the pains 
were very little influenced but the suffering 
was greatly lessened, and he found the 
method safe for the mother. 

Earning, in the same clinic, continued 
Wartapetian 's investigations and reported 
on thirty-six cases. He made the first in- 
jection consist of scopolamine 0.0003 (gr. 
1/200) and morphine 0.007 (gr. 1/9). This 
small quantity produced no results, and he 
then repeated the same dose of scopola- 
mine, with double the morphine. All but 
three of the mothers were relieved. He 
found that some of the patients became 
very much excited. When using frequently 
repeated doses he found that the strength 
and duration of the pains were much les- 
sened, but never to the extent of harming 
the mother or child. He saw no real com- 
plications during the labor. Only one child 
in this series was born asphyxiated. Dur- 



18 TWILIGHT SLEEP 

ing the same year Weingarten reported 
forty-five cases from the University of 
Giessen. He gave only one injection of 
scopolamine, 0.0003 (gr. 1/200) and mor- 
phine 0.01 (gr. 1/6), bnt nevertheless 
found that in thirty-eight cases the pains 
were decidedly lessened and in six cases 
partially so. There were no delayed de- 
liveries. In two cases the interval between 
the pains was shortened, and in sixteen the 
pains were steadied. Four of the children 
were born asphyxiated, but he ascribed this 
condition to causes other than the drugs. 
He saw no post-partum hemorrhages. 
There were four forceps cases and one 
version in no way caused by this treat- 
ment. 

Ziffer reported thirty-one cases from 
the Landers Hebammen Schule, using the 
same dosage as Weingarten, having had 
his drug specially prepared. He believed 
that in one third of his cases the pains 
became less frequent and in some of them 



TWILIGHT SLEEP 19 

weaker. He says, "This delay was so 
slight and so uni m portant that it did not 
in any way disturb the labor. ' ' Five chil- 
dren were born asphyxiated with one 
death, the latter due to premature separa- 
tion of the placenta. He did not believe 
that in any of these cases the asphyxiation 
was due to the scopolamine. The mothers 
certainly were relieved of suffering. 

In 1904 Pushnig also reported on sixty- 
two cases he had observed. His drugs were 
prepared according to Ziffer's method, but 
he used scopolamine 0.0005 (gr. 1/120) 
and morphine 0.01 (gr. 1/6), seldom re- 
peating the dose. The diminution of pain 
he reports as extreme in fifteen cases, great 
in forty-two, only slight in one and absent 
in four. He saw no harm from the injec- 
tion. The uterine contractions were un- 
altered in thirty-six cases. They improved 
in thirteen cases out of nineteen in which 
the pains were weak at the time of injec- 
tion. In two instances the pains were vari- 



20 TWILIGHT SLEEP 

able. In five cases the contractions became 
weaker after the injection, but he did not 
believe this to be due to the drug. The 
third stage of labor was not lengthened. 
There was slight atonic bleeding in ten 
cases. There were eight still-births, and 
six babies were born asphyxiated, but so 
little did he blame the drug for these that 
he considered the method "a work of 
mercy. ' ' 

Pisarzewsky, working in Poland, re- 
ported three cases. He used scopolamine 
0.0003 (gr. 1/200) and morphine 0.0007 
(gr. 1/95), repeated when needed. He 
noted a decided diminution of the suffer- 
ing, but also a lessening of the contractions. 
All three babies breathed spontaneously. 
There was no post-partum bleeding. 

Laurendeau, in 1905, reported in the 
Presse Medicale fifteen cases, in which he 
had used scopolamine 0.0014 (gr. 1/50) 
and morphine 0.014 (gr. 1/5). All of these 
cases were complicated, and operative 



TWILIGHT SLEEP 21 

procedure seems to have been contemplated 
before the injections were even started. 
They finally required either forceps or ver- 
sion. 

Muller, who reported in the Monatshefte 
fur Gynakologie und Geburtshilfe in 1906, 
used scopolamine 0.001 (gr. 1/600) and 
morphine 0.01 (gr. 1/6). He obtained anal- 
gesia and drowsiness. The contractions 
when influenced were benefited and he saw 
no complications when using fresh prepara- 
tions. 

Cremer, in a popular article entitled 
"Entbindung ohne Schmerzen," was the 
first to recommend the use of scopolamine 
and morphine in private obstetrical prac- 
tice. He considered the treatment harm- 
less when used with care. Later he twice 
reported in the Aertzliche Vierteljahres 
Rundschau. The 1908 report was based 
on 134 cases which were completed without 
harm to mother or child. He used scopo- 
lamine 0.0003 (gr. 1/200) and morphine 



22 TWILIGHT SLEEP 

0.01 (gr. 1/6). This dose was repeated 
after fifty minutes and again in two and a 
half hours. Cremer also drew attention to 
the value of these drugs in eclampsia. 

Bertino reported in La Ginecologia, 
volume IV, the use of scopolamine 0.0005 
(gr. 1/120) and morphine 0.01 (gr. 1/6) 
in 400 cases. He obtained painlessness 
without disturbance of labor in 45% of 
his cases and saw no results in 36%. 
Thirty-eight times the contractions re- 
mained absent from seven hours to several 
days. In seventy cases he observed dis- 
turbances of vision, and brain symp- 
toms which lasted sometimes for days. He 
found that the children were frequently 
apneic or asphyxiated. He did not ap- 
prove of the use of this method. His re- 
port is not complete or satisfactory and 
it should be noted that he used larger doses 
than those recommended by von Stein- 
buchel. 

It was about this time that Gauss, of 



TWILIGHT SLEEP 23 

Freiburg", undertook the Steinbuchel treat- 
ment. He observed 300 cases and reported 
his results in the Arcliiv fur Gyn-akologie, 
1906. This was the first of his now famous 
articles on this subject. He developed a 
technique which has become the standard 
and to which he applied the term Dammer- 
sclilaf (Twilight Sleep). He administered 
the combination of drugs in such a way 
as to produce not alone analgesia, in a 
certain number of cases, but also amnesia, 
in a very large proportion of them. Though 
realizing certain shortcomings in the 
method, Gauss was most enthusiastic 
about its eventual development. In this 
article he stated that he had seen in the 
literature reports of only 225 cases, al- 
though we find over 600 previous to his 
communication. 

After discussing the justification for 
reducing labor pains when possible, he 
says that any method to be finally ac- 
cepted must first of all cause a consider- 



24 TWILIGHT SLEEP 

able reduction of the suffering of the 
mother, and any unpleasant effects which 
the method produces must be harmless. 
Furthermore, the unpleasant symptoms 
must be less objectionable than the pain 
which the drugs are alleviating. He gave 
the drugs at intervals, dependent chiefly 
on the mental condition of the mother and 
the strength of the fetal heart. Though 
von Steinbuchel had noted that some of 
the patients experienced a temporary loss 
of memory, he had looked upon this as 
rather a secondary effect of the treatment. 
Gauss came to the conclusion that though 
analgesia was most welcome whenever it 
occurred, it was the temporary loss of 
memory (amnesia) which would be the 
criterion of success. 

His second contribution, entitled "Ge- 

burten in Kiinstlichen Dammerschlaf. " 

which appeared in the Archiv fur Gynako- 

ie. Band 75, Heft 3. is probably the 

most detailed of his articles and deals 



TWILIGHT SLEEP 25 

with his first 500 cases. He says that 
besides the two principles already men- 
tioned, it is most important that the 
treatment shonld prodnce neither nausea 
nor other subjective disturbances. The 
regular advancement of labor mns: not be 
unfavorably influenced by a change in the 
uterine contractions or the abdominal 
p rea sore. There must be no harmful effect 
on the after-pains or disturbance of the 
nursing, or impairment of puerperal in- 
volution. The child mns: not suffer before 
birth. There must be no hindrance after 
birth to the establishment of the new : 
tions either in the first weeks of existence 
or in the later development. In his earlier 
sases Ganss did not begin his injections 
until the labor had advanced so far that if 
any complications due to the treatment 
arose, the child could be delivered at n 
by forceps or some other not too severe 
operative procedure. From the very first 
he ruled out cases with primary weak 



26 TWILIGHT SLEEP 

pains, narrow pelvis, placenta prsevia and 
cases with a history of disturbances during 
the third stage of labor after previous 
deliveries. Later the contra-indications 
became less and only cases of primary in- 
ertia were excluded from this treatment. 
The 500 cases tabulated in this article were 
68.3% of all cases confined at the hospital 
during this period. There were 233 primip- 
arae and 267 multipara. The average age 
of the former was 24 years, of the latter 
30 years. There were 483 vertex presenta- 
tions, six face presentations, four breech 
and seven transverse presentations. 

As complications in these 500 cases 
Gauss gives the following table : 

Cases 

Narrow pelvis 40 

Hydramnios 5 

Prolapse of the cord 4 

Nephritis 2 

Eclampsia 3 

Premature separation of placenta 2 

Placenta preevia 3 

Habitual adherent placenta 1 

Habitual post-partum hemorrhage 1 



TWILIGHT SLEEP 27 

Cases 

Rupture of the cervix 2 

Myoma of the uterus 2 

Twists of the cord 1 

Intra-partum fever 15 

Pneumonia 1 

Peritonitis 1 



Four hundred and thirty-f our of the 483 
vertex cases were spontaneously delivered. 
Forty-nine were completed with forceps, 
fourteen for the sake of the mother, 
twenty- two for the sake of the child and 
the others because of a relative indication. 
There were four cases of subcutaneous he- 
botomy, also one classical and one vaginal 
Caesarian section. There were four cases 
of version, one because of placenta prsevia, 
one because of prolapse of the cord. In 
a case of twins, both babies were delivered 
by version on account of high fever in 
the mother. There were eight cases of ver- 
sion because of the transverse position. 
The breech cases progressed without help 
until that point was reached at which 



28 TWILIGHT SLEEP 

practically all breech cases must be inter- 
fered with. There were forty-two minor 
operations performed, thirty of which were 
sntnres of the perineum. In the third 
stage of labor the cavity of the uterus was 
examined four times to make certain that 
the entire placenta had been delivered. In 
three cases manual extraction was neces- 
sary, twice because of bleeding, and once 
because of habitual adherence and begin- 
ning fever. 

Gauss attached importance to the par- 
ticular preparation of scopolamine used. 
It must be remembered that this drug is 
rather an indefinite substance, and some 
authorities still insist that it is not pure, 
and that it may differ from the substance 
known as hyoscine. Gauss used either the 
powder or tablet, the important point being 
that he made his own solutions. He be- 
lieved that the irregular effects noted by 
some observers were due in part to in- 
dividual idiosyncrasies to the drug. He 



TWILIGHT SLEEP 29 

saw seeming irregularities from injections 
made from the same solution, injected at 
almost the same time into different 
patients. Nevertheless he was very care- 
ful with his solutions and preserved them 
at an even temperature away from the 
light and moisture. The scopolamine and 
morphine were separately sterilized and 
only thereafter, if at all, made into one 
solution. He believed that with this care 
solutions could be kept for more than a 
year. The syringe that he used was always 
freshly sterilized and kept as free as pos- 
sible from disinfecting fluids. The patient 
was carefully watched and the dosage ar- 
ranged accordingly. 

He described the action of the drug 
about as follows: shortly after the first 
injection the patient became tired and soon 
fell into a quiet sleep between the pains, 
from which she was aroused at each new 
contraction. Objectively the contractions 
are still painful, but subjectively the more 



30 TWILIGHT SLEEP 

intelligent patients admitted that they 
were suffering little, if at all. Later, the 
patient became thirsty, had dryness of the 
mouth and throat, a redness of the face, a 
certain amount of twitching of the mus- 
cles, and sometimes restlessness. When 
very deep the pain is only objective, and 
noticeable by the peculiar facial expres- 
sions. Memory is still present. This is 
the state which all workers before Gauss 
attempted to produce. He went further 
and tried to abolish memory itself, so that 
the absence of the memory of all pain 
would be the final outcome. To obtain this 
he found it necessary to increase the dos- 
age only slightly. Amnesia could not be 
produced in every case. Five or six per 
cent of his cases entered the hospital too 
late, and the only result from the injections 
in these cases was a quiet, restful sleep. 
When all was over, 18.2% of the cases were 
greatly relieved of pain during the labor, 
but did not reach the stage of amnesia. 



TWILIGHT SLEEP 31 

Seventy-six per cent of his cases showed 
distinct amnesia. The picture presented 
by these patients in labor naturally varied. 
The greater number appeared sleepy but 
otherwise normal, every contraction arous- 
ing the patient with a slight sensation of 
pain. Every question was sleepily but cor- 
rectly answered, and it was surprising to 
see that patients who seemed to have com- 
plete control of their senses were abso- 
lutely without remembrance of the labor 
when it was over. These patients were so 
nearly awake that one could hardly call it 
semi-narcosis. They were really in an arti- 
ficial condition of sleep from which they 
could be awakened at any moment but of 
which they retained no memory. It was 
this new type of semi-narcosis which Gauss 
termed an artificial ' ' Twilight Sleep. ' ' In 
the most successful cases where the 
patients were under to just the proper 
degree, they would say, ' ' Thank God, it is 
all over, ' ' as the baby was finally expelled, 



32 TWILIGHT SLEEP 

but a little later would not even know that 
the child had been born. Sometimes when 
her child was brought to her the mother 
thought it belonged to some other woman 
as she could not believe she was already 
delivered. The more intelligent who had 
been told in advance what was to be at- 
tempted were naturally overjoyed when 
they found that theirs had been a success- 
ful case. A very small number presented 
quite another phase. They were either in 
such a deep sleep that they could hardly 
be aroused or so restless and unruly that 
they could hardly be kept in bed. But none 
of these patients had any remembrance of 
the labor when it was over. 

The value of this amnesia to almost all 
classes of patients cannot be doubted. It 
saves physical and mental suffering and 
removes fear in a succeeding labor. It is 
certain that these patients recovered more 
rapidly and with less general shock than 
did patients not treated with this method. 



TWILIGHT SLEEP 33 

After a deep sleep following the scopol- 
amine labor they awoke strong, refreshed 
and frequently ready to eat and act as if 
nothing unusual had occurred. When 
operative interference became necessary in 
these cases it could often be accomplished 
with little or no additional narcotics. 
There was no stage of excitement when 
general anesthesia was used after these 
drugs and the patient frequently did not 
know that a general anesthetic had been 
given. 

The amount of scopolamine and mor- 
phine used was very much less than had 
been required in surgery. The lying-in 
woman is much more susceptible to drugs 
than other subjects. The dose must never 
be so large as to cause a cessation of activ- 
ity in the expelling forces, for it is well 
recognized that over-dosage with these 
drugs would bring about such a result. 
Finally, deep narcosis in the surgical sense 
is unnecessary and undesirable. Various 



34 TWILIGHT SLEEP 

doses were tried, sometimes scopolamine 
alone and sometimes with a greatly in- 
creased amount of morphine. The solu- 
tions were scopolamine 0.03% and mor- 
phine 1% and were used as long as they 
remained clear. The dose was varied with 
the general physical make-up of the pa- 
tient. The largest dose was scopolamine 
0.0036 (gr. 1/18) over a period of thirty-six 
hours, the longest case lasting fifty-seven 
hours, the patient receiving scopolamine 
0.00375 (gr. 1/17) and morphine 0.03 (gr. 
%). The technical difficulty lies in giving 
the patient sufficiently frequent injections 
of sufficiently small doses to keep her am- 
nesic and still superficial enough to pre- 
vent harm. 

As a result of the work of Link it was 
found that the Babinski reflex was one of 
the earliest signs of scopolamine action. 
The pupil reflexes were not much altered 
but muscular coordination was disturbed. 
The only reactions that Gauss found of 



TWILIGHT SLEEP 35 

real use were sensibility of the pupil, the 
lack of muscular coordination, and above 
all, the memory test. 

The meaning of amnesia Gauss discusses 
at length. The amnesia produced by sco- 
polamine and morphine is not a loss of 
memory of previous events but is an in- 
ability to remember what is transpiring 
while under the influence of the drug. It 
seems that the drugs prevent impressions 
from being sufficiently imprinted on the 
brain cells to be held there, though they 
temporarily enter consciousness. Hence, 
Gauss deduced that, working in the reverse 
direction, he could tell from the depth of 
the amnesia the stage of the Twilight 
Sleep. After arriving at this conclusion 
he made his dosage almost entirely de- 
pendent upon the depth of the amnesia. 
In cases where a difference of language or 
extreme ignorance or dementia of the pa- 
tient or any other reason precluded the 
use of the memory test, he resorted to 



36 TWILIGHT SLEEP 

sensibility of the pupil and muscular co- 
ordination as tests. After schematically 
arranging the various reactions it was 
found that the spinal reflex was the best 
indicator of the beginning action of the 
drugs, but the ideal point to be reached 
was the state of amnesia which comes 
about the time that the spinal reflexes are 
lost. 

This complicated explanation of the vari- 
ous symptoms shows conclusively that it is 
not always easy to keep the patient in just 
the ideal state; and that it requires the 
most careful and persistent watching on 
the part of the attending obstetrician and 
his assistants from the first injection to 
the completion of labor. 

Gauss found that he obtained his best 
results when the patient was alone in a 
quiet room, away from all disturbing ele- 
ments, with her mind at ease and a desire 
for Twilight Sleep. Even the crying of the 
newlv-born infant was at times sufficient to 



TWILIGHT SLEEP 37 

cause a disturbance in the amnesia, making 
it advisable to promptly remove the child 
to another room. Dark glasses and stuf- 
fing the ears of the mother were found to 
be a great help in preventing perception of 
light and noise. Sometimes the patient 
would only remember being transferred 
from the bed to the operating table, or 
her only recollection might be the actual 
birth. Such events seemed to be remem- 
bered more readily than was the sensa- 
tion of pain whether produced by uterine 
contraction, abdominal pressure, forceps, 
or suturing the perineum. These iso- 
lated memories Gauss called "Islands of 
memory," and found that when they oc- 
curred too frequently during labor, the 
patient would reconstruct from them the 
entire course of labor. In this reconstruc- 
tion she would be guided by her knowledge 
of labors in general, and by what she had 
heard during her awakening. It was some- 
times very difficult to convince such pa- 



38 TWILIGHT SLEEP 

tients that they had slept during most of 
the labor. 

The complications which Gauss found in 
scopolamine labors he discusses under the 
headings of mother and child, subjective 
and objective. The annoying thirst he 
overcame by large quantities of water and 
never saw any resulting harm. Minor dis- 
turbances of hearing and sight, such as 
answering questions which had not been 
asked and seeing things which did not exist, 
caused no real trouble. Melanopia and hal- 
lucinations were likewise of little moment. 
The first and probably the most important 
matter discussed under "Objective Com- 
plications " was the lessening of the 
uterine contractions. He made notes on 
these contractions in 493 of his cases. In 
451 of them there seemed to be no effect. 
Eight were decidedly worse after the in- 
jection and thirty-six were greatly im- 
proved. Schlimpert, who by means of 
schematic charts studied the contractions 



TWILIGHT SLEEP 39 

for Gauss, showed that the pains were reg- 
ulated, though the periods between them 
were frequently lengthened. The duration 
of the contractions themselves was also 
frequently lengthened. 

The abdominal muscles were very little 
interfered with by the drugs. "When the 
separate doses were sufficiently small the 
results were very good. When large doses 
were given the contractions of these mus- 
cles were at times definitely weakened. 
This was pronounced with morphine and 
much less so with scopolamine. That what- 
ever decrease of the abdominal work did 
exist was of very little importance is shown 
by the comparatively small number of 
operations. In the entire series of 500 
labors with its 506 deliveries, there were 
forty-nine forceps cases, nine versions 
(two of which followed vaginal Caesarian), 
one abdominal Caesarian and four heboto- 
mies. This is an operative interference of 
only 12.6%, which is almost identical with 



40 TWILIGHT SLEEP 

the operative frequence reported by Ploe- 
ger, in non-scopolamine cases at the Uni- 
versity Frauenklinik of Berlin. Of the 
sixty-three operated cases thirty-seven 
were primiparae and twenty-six multipara. 

The average duration of these labors 
was sixteen hours and eleven minutes. 
This is well within the limit set by other 
observers for non-scopolamine cases. If 
in any particular case the labor is being 
unduly delayed by the use of the drugs, a 
rare occurrence, it is always possible to 
stop the treatment and allow the woman to 
press with the abdominal as well as the 
uterine muscles and complete the labor 
naturally. Nothing is lost by this ; on the 
contrary the woman is spared a certain 
amount of pain during the first stage. 

The expulsion of the placenta without 
help occurred in 56% of the cases. Crede's 
method was resorted to in 43%. In 0.6% 
manual extraction was employed. In the 
other 0.4% of the cases the placenta was 



TWILIGHT SLEEP 41 

removed as a part of the operative inter- 
ference. Ganss gives the frequency of 
mannal extraction reported by twenty ob- 
servers as ranging from 0.3% to 7.3%, thus 
definitely proving that it is not by any 
means increased by the use of these drugs. 
There were only twenty cases of bleeding 
beyond what could be noted as slight, and 
all these were in Crede's cases and were 
easily controlled by uterine massage. 

Gauss carefully compared the milk secre- 
tion in 200 cases treated with scopolamine 
and morphine and 200 delivered during the 
same time without these drugs. He gives 
the following table, which speaks for it- 
self: 

WITHOUT VTTTH 

SCOPOLAMINE SCOPOLAMINE 

AND MORPHINE AND MORPHINE 

Nursed of their own 

accord 137, or 68.5% 134, or 67% 

Forced feeding ... 8, or 4% 15, or 7.5% 

No milk 55, or 27.5% 51, or 25.5% 

The involution of the uterus and its re- 
turn to normal was not fully observed be- 



42 TWILIGHT SLEEP 

cause most of the patients left the hospital 
about the seventh day. Late post-partum 
hemorrhages were never seen. Both clinic- 
ally and experimentally Gauss established 
to his own satisfaction that the drugs in 
no way affected the kidneys. Phlebitis he 
noted in five of his cases, one of which had 
had the same complication in a previous 
non-scopolamine labor. Three of the five 
cases had undergone hebotomy. He had 
no maternal death under the treatment, nor 
as a result of it. There were no other 
complications in the mother. There were 
two cases of post-partum eclampsia, one of 
which had two convulsions before the treat- 
ment was started, and then another after 
her first injection, and no more. 

The most common objection at present 
raised to this treatment is its supposed 
increased risk to the child. Of the 506 
children (six twins) there were 500 
(98.8%) living, six (1.2%) still-born. Of the 
500, 306 breathed spontaneously, though 



TWILIGHT SLEEP 43 

four of these were premature and died 
shortly after birth. One hundred and nine- 
teen were born oligopneic, that is to say 
they took one deep breath at birth with 
more or less of a cry and then, despite 
movements of the extremities and regular 
heart action, their breathing ceased for a 
short period. When respiration was rees- 
tablished it was at first very slow, but 
gradually became more frequent. In 
fifteen to twenty minutes at the most 
the child became normal and remained 
so. While the respirations were infre- 
quent there would be some cyanosis be- 
tween breaths, the eyelids would move, 
the pupils become somewhat dilated, and 
the child would appear extremely drowsy. 
In the larger number of cases this condi- 
tion of oligopnea is due to the use of the 
drugs. With increased experience the per- 
centage of oligopnea became very small, 
and no eventual harm resulted. 

Sixty-five of the living children were 



44 TWILIGHT SLEEP 

born asphyxiated. Forty-seven times this 
was definitely ascribable to conditions 
aside from the Twilight Sleep. In the 
eighteen remaining cases it was not possi- 
ble to fix the canse, just as it is often im- 
possible in non-scopolamine cases to defi- 
nitely explain this condition. In some of 
them injections had probably been given 
too close to the moment of birth. Five 
of this series of babies finally died. One 
was passing meconium before birth and 
showed slow, irregular, feeble heart 
sounds. Two had aspirated large quanti- 
ties of mucus and were born spontaneously 
before forceps could be applied. The 
fourth was in a narrow pelvis necessitating 
forceps application, and the child tem- 
porarily recovered to die the next day with 
cerebral symptoms. The fifth showed cere- 
bral symptoms from the start, probably 
the result of forceps, and died after five 
hours. Of the five still-births, one was 
dead before the treatment was started, one 



TWILIGHT SLEEP 45 

died intra-uterine as a result of placenta 
praevia and version, one died during a pro- 
longed labor in a narrow pelvis because 
the fetal heart sounds were not sufficiently 
watched. The fourth case was due to ver- 
sion and a prolapse of the cord. The fifth 
was a breech case which went unobserved 
during the entire birth. After the body- 
was delivered the head was held in the 
vagina as a result of several loops of cord 
about the neck. This case could have been 
saved had it been properly watched. In 
addition eighteen died between the third 
and fourteenth days, five from infection of 
the cord, ten as a result of prematurity, 
and three as a result of deformities. To 
learn whether the children of this series 
had suffered more than non-scopolamine 
cases Gauss compared these results with 
twenty-five hundred cases which had 
been delivered from 1895 to 1904 in the 
same institution, and found the comparison 
very favorable to Twilight Sleep. The 



46 TWILIGHT SLEEP 

later history of the children, as far as it 
could be investigated, did not lessen the 
value of the treatment. 

As a result of this work, Gauss came to 
the following conclusions : Twilight Sleep 
greatly lessens the suffering of the lying-in 
woman. This result is obtained without 
secondary unpleasant subjective symp- 
toms, without appreciable influence on la- 
bor itself, and without danger to mother 
or child. In teaching institutions it allows 
vaginal examinations by students without 
annoyance to the patient. And finally he 
says: "The scopolamine and morphine 
Twilight Sleep in labor is a previously un- 
attained method which promises great hope 
for the doctor, the patient, the teacher and 
the pupil.' ' 

Later Gauss and various of his students 
at Freiburg reported at length, adding 
nothing new, but emphasized the important 
points discussed above. Bruti, of Buenos 
Ayres, reported in the Medizinische 



TWILIGHT SLEEP 47 

Klinik, 1909, 600 cases from Freiburg 
where he was then assistant. He made 
one additional interesting observation, 
namely, that the results were successful in 
81% of the first class cases, 70% of the 
second class, and about 60% of the third 
and fourth classes.* He ascribes the bet- 
ter results in the first class to the fact that 
the patients were in a room alone, that 
they were treated by more experienced 
doctors and nurses, and that they received 
better care. 

A series of 500 cases as reported in 
1906 from so important a clinic as that 
of the University of Baden in Freiburg 
further stimulated work throughout Eu- 
rope and America. The reports that fol- 
lowed did not all agree with Gauss's deduc- 
tions. 

Hocheisen, working in Bumm's clinic at 

* In Freiburg ' ' first class ' ' corresponds to our pri- 
vate patients; whereas "second class" are more like our 
semi-private cases, and the third and fourth classes are 
ward patients. 



48 TWILIGHT SLEEP 

the Charite in Berlin, and Steffen the fol- 
lowing year gave emphatic expression of 
their dissatisfaction with the treatment. 
Probably on this account, and because of 
the prominence of Bumm, and despite some 
other favorable articles and Gauss's fur- 
ther report of 500 additional cases, the 
method was not generally adopted. 

Hocheisen reported 100 cases. Forty of 
these were his own and the other sixty were 
attended by Bardeleben. He first reviewed 
the work of Gauss, and then considered 
scopolamine in its pharmacological aspect. 
He believed it to be a severe poison, unde- 
pendable in its action. As part proof he 
quoted a gynecological death that had oc- 
curred at Budapest. The fatality was sup- 
posed to have been caused by a single in- 
jection of scopolamine 0.0003 (gr. 1/200). 
It is interesting to note in passing that 
Frigyesi, of Budapest, also reports this 
same case. He says that the woman, after 
having had a laparotomy performed in the 



TWILIGHT SLEEP 49 

morning, was reoperated in the afternoon 
for a probable secondary hemorrhage. 
Three days later the patient died. 

With this case in mind and because of 
possible dangers, Hocheisen believed that 
much smaller doses were necessary than 
those given by Gauss. His largest total 
dosage was scopolamine 0.002 (gr. 1/30) 
and only in one case more than morphine 
0.02 (gr. 1/3). The patients were not 
isolated nor given the quiet that Gauss 
found valuable. Hocheisen did not use the 
spinal reflex or the memory test to ascer- 
tain the condition of the woman. He stated 
once in a discussion on this subject that 
the drug was given until the woman showed 
no more signs of pain. From this it will 
be seen that no matter what is said in favor 
of Hocheisen 's work, the conclusion he 
reached proved nothing in respect to the 
Freiburg method, from which he wandered 
far. His work is simply a criticism of the 
value of these drugs as they were used in 



50 TWILIGHT SLEEP 

Bumm's clinic. His results lie reported 
as follows : 

Per Cent. 

Absence of analgesia 18 

Partial analgesia 21 

Complete analgesia 61 

Prolonged labor 50 

Bleeding 5 

Expression of placenta 4 

Still-birth 1 

Died after birth 3 

Forceps cases 6 

Extraction of fetus 1 

In only six cases did he note amnesia. 
As complications he gives : 

Cases 

Vomiting 6 

Vertigo 2 

Flushing of the face 60 

Headache 6 

Severe perspiration 2 

Great restlessness 10 

Hallucinations 4 

Clonic twitchings 3 

He admits that so far as the patient is 
concerned these complications do not 
amount to much ; but to the observers who 
expect to see a painless birth and a deep 
sleep the impression is anything but pleas- 



TWILIGHT SLEEP 51 

ant. He further says that in sixty-four of 
his cases the contractions were not influ- 
enced. Once they became more quiet and 
stronger. During the first period of labor 
they were weakened in twenty-one cases. 
During the second stage of labor the con- 
tractions were lessened in twenty-three 
cases, and in three they ceased altogether. 
The contractions of the abdominal muscles 
were lessened in 15%, very much lessened 
in 4% and increased in only 1%. As a 
result, 50% of the labors were prolonged. 
Even in the third stage of labor he had 
troubles which he ascribed to the drugs. 
He had five cases of atonic bleeding, in 
thirteen there was difficulty in releasing 
the placenta; four times it had to be ex- 
pressed because of bleeding. He saw also 
fifteen cases of subinvolution, one case of 
severe dyspnea with nephritis of preg- 
nancy, and one case of severe cardiac 
disturbance. One woman died from atonic 
bleeding, having lost % litre of blood, the 



52 TWILIGHT SLEEP 

death resembling that produced by inject- 
ing animals with scopolamine. Of the chil- 
dren, eighteen were born oligopneic, fifteen 
asphyxiated; one child died during deliv- 
ery and three after delivery. 

Of course with such results, Hocheisen 
objected very strongly to Twilight Sleep. 
Scopolamine is recognized as a dangerous 
drug when used in large doses, but the 
small doses needed in obstetrics are less 
dangerous than Hocheisen's results would 
lead us to suppose. 

Lehman reported seventy cases in which 
he used scopolamine 0.0003 (gr. 1/200) 
and morphine 0.01 (gr. 1/6). As a rule 
two injections were sufficient but when a 
third was necessary it was given at least 
two hours later. His aim was always anal- 
gesia. This was a return to the method 
of von Steinbuchel, but he obtained very 
different results than did Hocheisen. In 
61.6% of all Lehman's cases there was 
complete analgesia, in 37% partial, and in 



TWILIGHT SLEEP 53 

1.4% the results were negative. The con- 
tractions remained unaltered in 58.7%, 
were improved in 25% and became weaker 
in 16.3%. He noted that some of the 
patients, probably because of absence of 
pain, used the abdominal muscles to 
greater advantage than before they re- 
ceived the injection. Others, because of the 
depth of the analgesia, hardly used them 
at all. The third stage of labor was not 
interfered with, there being but one atonic 
bleeding, in a case that had suffered from 
a post-partum hemorrhage in a previous 
non-scopolamine labor. He frequently 
noted an absence of after-pains. Lacta- 
tion was normal. 13.3% of the children 
were born asphyxiated, 10% oligopneic, the 
remainder breathed spontaneously. One 
under-developed child died after two days, 
but Lehman does not ascribe this fatality 
to the drug. The other complications were 
negligible, and he concluded that the proce- 
dure was safe and valuable, giving warn- 



54 TWILIGHT SLEEP 

ing, however, that it must be used only 
where the cases can be carefully watched. 
Preller observed 120 cases. He tried to 
follow the technique of Gauss ; his highest 
dose was scopolamine 0.0005 (gr. 1/130) 
and morphine 0.02 (gr. 1/3). He obtained 
amnesia in 70%, analgesia in 18%. In 
12% the results were negative, chiefly due 
to rapid delivery. The contractions were 
favorably influenced in from 5% to 6% 
and unfavorably in from 24% to 25%,. 
They ceased entirely in two cases. The 
abdominal contractions were absent in 25% 
and he believed this to be due to the com- 
paratively large doses of morphine. He 
did not think that this visible lessening of 
the contractions was as real as might be 
inferred, but simply that the contractions 
went on so quietly that they were not fully 
observed ; otherwise the labors would have 
been lengthened and the operative fre- 
quency increased. Seven and six tenths 
per cent of the cases required interfer- 



TWILIGHT SLEEP 55 

ence against 8.4% in which the drugs 
were not used. Only twice did he 
remove the placenta by hand and there 
were only four cases of atonic bleeding, 
one of which appeared very late. He 
noted that frequently the maternal heart 
sounds were improved. In 20% of the 
cases, however, irregularity of the pulse 
developed and then the treatment was dis- 
continued. Occasionally he observed con- 
siderable muscular twitchings. There 
were vomiting and vertigo in 8% of the 
cases and mild delirium in 5%. Two cases 
showed psycho-motor excitement, but the 
labors terminated normally, and after a 
deep sleep the mother awoke entirely re- 
freshed. The scopolamine mothers, it was 
noticed, showed less post-partum exhaus- 
tion and only five complained of pressure 
of the head and heaviness of the joints. 
Only one child died, and that was in a case 
where the mother had fever. Five per cent 
were born apneic, 25% oligopneic. There 



56 TWILIGHT SLEEP 

was no permanent harm in any case. Prel- 
ler concludes that as long as there is no 
more serious harm reported as a result of 
Twilight Sleep it must remain a clinical 
method for diminishing the sufferings of 
the mother, entirely justified if used with 
care. 

The next important work which ap- 
peared upon the continent was by StefTen, 
who reported 300 cases. The first dose 
given by him was morphine 0.01 (gr. 1/6) 
and scopolamine 0.00045 (gr. 1/145), and 
no further injection was made until from 
three to six hours later. In general Stef- 
fen's total dosage was less than Gauss 
considered necessary. In 215 of his cases 
he gave no second injection. This was due 
either to the appearance of complications 
or because the labor was completed before 
he considered a second dose necessary. 
He claimed that the fetal heart sounds re- 
quired constant watching, but that none of 
the other symptoms depended upon by 



TWILIGHT SLEEP 57 

Gauss in controlling these cases were im- 
portant. In most details he disregarded 
Gauss's technique. His reports were most 
encouraging, although he was not in favor 
of the treatment. 

In 41.7% the results were favorable; in 
52.7% unfavorable, and 5.6% of his cases 
remained uninfluenced by the drug. The 
contractions remained powerful in 56.1%, 
became weaker in 38.3% and stopped in 
5%. They were improved in 0.6%?. The 
suffering was unchanged in 18.6%, lessened 
in 35%, increased in 0.6%?, and not noted 
in 45.8%. The use of the abdominal mus- 
cles remained good in 77%?. Thirteen per 
cent of his patients were restless and 
mildly delirious and he ascribes to the 
treatment a certain number of lacerations. 
Atonic post-partum hemorrhage occurred 
in 3.3%. A few cases vomited. He used 
the forceps in 5.3%? of his cases and be- 
lieved that most of the labors were length- 
ened. Sixteen per cent of the children 



58 TWILIGHT SLEEP 

were apneic and 2.3% were asphyxiated. 
Steffen concluded that the method of treat- 
ment did not secure the results desired, 
that it was not without danger, and could 
not be recommended in private practice. 
The spinal reflexes and the memory test 
on which Gauss placed so much stress were 
entirely ignored by Steffen. 

Mansfield, who spent six weeks at the 
Frauenklinik in Freiburg, reports in the 
Wiener klinische Wochenschrift, 1908. 
He emphasized the need of individualiza- 
tion. He says there must be practically no 
attention paid to analgesia, and that all 
dependence must be placed on the memory 
test to regulate the dosage. If complete 
analgesia is accomplished there is great 
danger of over-dosage. The memory test 
when conscientiously used brings success 
without harm. 

Bass, who considered the method useful, 
reported 107 cases with results which were 
much like Gauss's. He had an operative 



TWILIGHT SLEEP 59 

frequency of 9.3% and claims that in only 
one case could the necessity of operation 
be ascribed to the drug. Nine of the babies 
were born oligopneic and there was one 
death which Bass ascribed to the injec- 
tions. Four children were born asphyxi- 
ated after operative interference. There 
were three still-births in no way due to the 
drug. He felt that labor was often pro- 
longed, but without harm to the mother or 
child. The uterine contractions and the 
third stage were seldom influenced but the 
abdominal muscles frequently became less 
active. 

Geminder observed 100 cases. He did 
not strictly follow the Freiburg technique. 
He had good results in fifty-eight cases. 
The labor was uninfluenced in eighteen, and 
much delayed in twenty-four, of which 
eight came to a complete standstill. Oper- 
ation was indicated in nine cases. Cyano- 
sis and irregular pulse occurred in four of 
the mothers, atonic after-bleeding in five. 



60 TWILIGHT SLEEP 

Fifteen of the children were asphyxiated, 
twelve oligopneic, and fonr died during 
the first week. He concluded that the 
treatment could not be recommended, and 
especially warned against its use in private 
practice. 

Fabre and Bourret, in France, had two 
cases and were favorably impressed, both 
mothers having been greatly relieved with- 
out harm. 

Matwjejew found that labor was not 
prolonged and the suffering was either ab- 
sent or much relieved. The children were 
frequently born apneic, but he noted no 
other complications. 

Kleinerts had 280 cases in which he fol- 
lowed Gauss's instructions. His largest 
total dosage was scopolamine 0.00585 (gr. 
1/12) and morphine 0.01 (gr. 1/6). He 
obtained complete amnesia in 213, partial 
amnesia in thirty-four and in nineteen 
cases there was no amnesia. In fourteen 
cases there was no result because of rapid 



TWILIGHT SLEEP 61 

delivery. He claimed that the contractions 
were unfavorably influenced if he made his 
injections too early and in too rapid suc- 
cession. Except for thirst and dryness he 
saw no complications. In one case he dis- 
continued treatment because of a severe 
cardiac lesion, but even here some relief 
had been afforded. In twenty-nine cases 
he used the forceps, but claims that not 
once was the indication brought about by 
the drug. In three cases the placenta was 
extracted manually. The puerperium was 
in no way influenced. Most of the children 
breathed spontaneously, though a few were 
born oligopneic and fewer asphyxiated. 
There was no death in any way ascribable 
to the drug nor did it cause any later harm 
to the children. His conclusions in his own 
words were: "The procedure is, in my 
opinion, only to be used in the hospital, 
and there only when a doctor and a well-in- 
structed nurse have the time and patience 
to watch the case and to strictly follow the 



62 TWILIGHT SLEEP 

rules. Under these conditions we have a 
method which, without noticeable influence 
on the labor, or danger to the mother, or 
harm to the child, does away with the ap- 
perception of pain during the labor either 
entirely or to a very large degree.' ' 

Mayer, in the Zentralblats /. Gynakolo- 
gie, reported fifty cases in which he fol- 
lowed the Gauss technique. His results 
were satisfactory, but he also came to the 
conclusion that the method should be used 
only in institutions where there were suf- 
ficient trained assistants to give the cases 
the close scientific attention required. 

Dietschy, before trying the method at 
Basle, studied with Gauss at Freiburg. 
He found that the pains were weakened 
but that this in no way disturbed the labor. 
The children all did well and he found the 
method entirely satisfactory. 

Avarrffy did not practice the technique 
he had been taught while a student at Frei- 
burg. This probably accounted for the fact 



TWILIGHT SLEEP 63 

that his results were less satisfactory than 
those of Dietschy, Mayer, Kleinerts and 
Gauss. 

Frigyesi reported 200 cases from the 
Budapest Frauenklinik. He followed 
Gauss's technique but obtained only 62.5% 
amnesia. He ascribed this to the fact that 
so many of the cases resulted in such rapid 
delivery that there was time for only one 
injection. Taking into consideration only 
the cases in which several injections were 
given the percentage of complete amnesia 
rose to 80.7%. Analgesia without amnesia 
was present in 25%. There were dizziness 
and headache in 2%, slight excitement oc- 
curred in 7.5%. He believed that when the 
contractions were appreciably lessened the 
cause could be found in an overdose of 
morphine. As this is frequently difficult 
to avoid he finds it one of the few real 
objections to this method of treatment. 
Four of the children were born asphyxiated 
and thirty oligopneic. There was no ma- 



64 TWILIGHT SLEEP 

ternal or fetal mortality. The puerperium 
proceeded uninfluenced. 

Fehling reported in the Strasburger 
medizinische Zeitung, 1909. He had sixty- 
four cases with only 17% amnesia and 
hence was very little impressed with the 
method. He did not follow the Freiburg 
technique, and, as has been stated many 
times, amnesia cannot be expected if the 
memory test is not properly applied. 

Bosse, in conjunction with W. Eliasberg, 
in the Sammlung Minische Vortrdge fur 
Gynakologie, 1909, reported 122 successful 
cases. 

Reports in less detail and of less im- 
portance were also made by Hold, Klein 
and Berger. Their results were in the 
main very satisfactory. 

Shortly after Gauss's original article 
appeared, the treatment was tried in many 
parts of the world, notably in England 
and America, and will be reviewed in other 
chapters. 



TWILIGHT SLEEP 65 

From about 1909 until recently very little 
has been beard on the subject except from 
Freiburg, where Gauss, inspired by his 
chief, Prof. Kroenig, continued with the 
technique he had devised, so that to date 
he has had over 6,000 cases of Twilight 
Sleep, and is more than ever convinced of 
the value of the method and enthusiastic 
over his results. 

Since October, 1914, American medical 
literature has been abundantly supplied 
with articles on this subject. These will 
be discussed in a separate chapter. 

The literature here summarized and 
tabulated shows that the mother is always 
safe and that where the dosage is not reck- 
lessly high the infant is also unharmed. 
Dangers arise only as a result of neglect. 
These cases need the greatest of care and 
attention. Annoying complications can 
arise, but these are reduced to a minimum 
by experience and strict adherence to 
Gauss's technique. 



n 



THE FREIBURG TECHNIQUE OF TWILIGHT SLEEP 

Let us consider the details of the Frei- 
burg method of Twilight Sleep as we 
should apply it here in America. 

In preparation the physician must fully 
acquaint himself with what he expects the 
drugs to do, study the literature, and if 
possible see a few cases treated by some 
one who has had experience with the 
method. The obstetrician must be familiar 
with the condition of the patient, her meas- 
urements, and the position of the child. 
When labor starts the patient must be 
placed in a quiet, darkened room. Dark 
glasses, or a cloth over the eyes and plug- 
ging the ears are helpful in producing the 
necessary external effects. There must be 
plenty of doctors and nurses at hand to 



TWILIGHT SLEEP 67 

assist, and a supply of the usual parapher- 
nalia for instrumental child-birth — sterile 
linen, forceps, and so forth. 

When the labor pains have increased in 
force so as to produce at least two fingers 
dilatation of the cervix, and recur regu- 
larly every five or six minutes in pri- 
miparae, and not less than every seven or 
eight minutes in multipara, we are ready 
for our first injection. This is all im- 
portant, for primary inertia of the uterus 
is the one contra-indication. The first in- 
jection should consist of morphine hydro- 
chloride gr. 1/4, and scopolamine hydro- 
bromide gr. 1/150. From this moment the 
patient, and especially the fetal heart 
sounds, must be carefully watched. As a 
rule after fifteen or twenty minutes the 
patient will be quiet between pains, and 
may even sleep. During the pains she will 
probably still complain, but slightly less 
than before the injection was made. From 
forty-five to sixty minutes after the first 



68 TWILIGHT SLEEP 

injection, if all is well we are ready for the 
next hypodermic. All succeeding doses 
consist of scopolamine alone, the usual 
amount being gr. 1/450. From now on 
time plays no role whatever. My own 
experience, however, has shown that suc- 
ceeding injections are required every 
thirty minutes to two hours — the intervals 
becoming longer as the number of injec- 
tions increases. The fetal heart, the 
mother's pulse and general condition must 
be carefully watched and the memory test 
applied every ten or fifteen minutes. What 
we wish to discover is the stage at which 
the woman's memory for present events is 
absent but on the verge of returning. This 
memory test is the most exact method we 
have for determining the depth of the anes- 
thesia. It is most easily made by showing 
the patient some object, by catheterizing 
her if this is indicated, or by taking the 
temperature, and a few minutes later pre- 
tending to repeat the act. If on inquiry 



TWILIGHT SLEEP 69 

the patient has, no remembrance of the 
previous act she is sufficiently under the 
influence. If at the end of a uterine con- 
traction during which the patient showed 
signs of pain, she is not aware that it has 
taken place, this too shows in a definite way 
that there is loss of memory. If all is well 
then the slightest sign of returning mem- 
ory means that another dose of scopolam- 
ine must be given. The number of doses 
administered is of no importance. Over 
twenty injections have been reported in an 
individual case without harm. Three to 
seven injections suffice in the ordinary 
labor case. 

If the patient is only slightly under the 
influence, or on the verge of coming out, 
then any unusual noise, or a flash of light, 
or other external stimulation, may cause 
the memory of that event to persist. The 
increased pain at the moment of delivering 
the head may act as another such stimulus. 
This must be guarded against by the dos- 



70 TWILIGHT SLEEP 

age and depth of anesthesia, or by the ad- 
dition of a few drops of some general anes- 
thetic. These little awakenings of the 
memory have been termed by Gauss "isl- 
ands of memory/ ' and as elsewhere stated, 
if too many of these islands exist in any 
particular labor, the patient may mentally 
reconstruct the entire course of labor, and 
not believe that she does not remember 
every moment in the process of birth. 
Thus, as far as she is concerned, the case 
has been a failure. 

There are other points of importance to 
be watched besides the fetal heart, the 
mother's pulse and the amnesic condition. 
The general progress of labor must be 
observed. The dryness of the throat must 
be overcome by giving the patient frequent 
drinks of water, even though they are not 
asked for. The bladder must be catheter- 
ized because the analgesia existing is apt 
to cause the mother not to perceive its 
distention. Muscular coordination will 



TWILIGHT SLEEP 71 

early be absent and the pupillary reaction 
to pain will become less active as the sleep 
deepens. The small vessels of the face 
will dilate, causing flushing as a very early 
symptom. 

The first stage of labor will rarely be 
lengthened by this procedure. On the con- 
trary, it may be shortened. The second 
stage is recognized by most observers as 
requiring a little longer time than in non- 
scopolamine cases. I believe that most of 
this delay takes places after the head has 
reached the perineum. The length of time 
that it remains there is of itself not im- 
portant. Twilight Sleep observers have 
definitely proven that the old teaching that 
forceps must be applied when the head has 
been on the perineum an hour and a half 
to three hours, is incorrect ; and a delay at 
this stage of six to eight hours or even 
longer, will be absolutely harmless, if the 
fetal heart sounds remain good. 

If the mother does not use the abdominal 



72 TWILIGHT SLEEP 

muscles as she would have done without 
scopolamine, it is frequently possible to 
suggest, without awakening her, that she 
bear down. Often a small dose of pitui- 
trin * will complete the labor. It is cer- 
tainly not difficult for the obstetrician to 
apply forceps at this stage, provided the 
treatment has not been started until the 
cervix is at least two fingers dilated and 
the head engaged. If an emergency arises 
the labor can always be rapidly brought to 
a conclusion by manual dilatation and ap- 
plication of instruments. If the fetal heart 
sounds should become decidedly slower 
(below 100), or much more rapid (above 
170), it is always best to discontinue fur- 
ther treatment, and if then the fetal heart 
does not return to normal we should com- 
plete the labor as above suggested. 

As soon as the child is born it should be 
removed to another room, for the outcry 

* Pituitrin frequently does not work as powerfully as 
when scopolamine and morphine have not been used. 



TWILIGHT SLEEP 73 

of the infant might produce one of the 
islands of memory which we are trying to 
prevent. 

In my experience one of the most un- 
pleasant complications is the restlessness 
which may arise. In the extreme cases this 
is characterized by the patient throwing 
herself about, and with tremendous 
strength attempting to get out of bed. 
This in itself will not effect the end result 
of the Twilight Sleep, for the patient will 
not be aware when she awakes that she has 
not been quiet the entire time. It does, 
however, cause difficulty in preserving 
asepsis, and can only be overcome by a 
large number of assistants. In two of my 
cases at the Lebanon Hospital we discon- 
tinued the treatment because we could not 
control the delivery aseptically. This does 
not contra-indicate the method. The worst 
that can be said about it is that when there 
is not sufficient assistance we must discon- 
tinue the injections and allow the case to 



74 TWILIGHT SLEEP 

be recorded as one of only partial amnesia. 
With continued practice, a proper applica- 
tion of the memory test, and correct judg- 
ment of the depth of the ' ' Sleep, ' ' restless- 
ness becomes less frequent and will only 
exist when there is a distinct idiosyncrasy 
to scopolamine. 

The child having been removed to an- 
other room is treated in the usual manner. 
After a little experience, it is surprising 
how seldom oligopnea and asphyxia arise 
when the labor has progressed normally. 
If there is an oligopnea the infant may cry 
out once, and then with a regular but slow- 
beating heart it will refuse to breathe, and 
become more or less cyanotic. Left to it- 
self, I believe that in all cases the condi- 
tion will gradually disappear and the in- 
fant return to normal. Nevertheless, one 
ought to resort to the usual methods of 
resuscitation, for these will naturally 
hasten breathing. Asphyxia occurs just as 
often in non-scopolamine cases and, I be- 



TWILIGHT SLEEP 75 

lieve, is never caused by these drugs when 
they are properly used. 

While the baby is being thus attended 
the mother must be carefully watched. 
Though atonic post-partum bleeding will 
not occur more frequently than in ordi- 
nary deliveries, when it does occur the pa- 
tient will not draw attention to it, and 
hence must be observed for this contin- 
gency. On account of the slow dilatation 
of the vaginal outlet there should be few 
lacerations of the perineum. They can be 
sutured as usual, either with or without 
general anesthesia, depending on the depth 
of the scopolamine narcosis. 

Everything being completed, the mother 
will fall into a deep sleep lasting from half 
an hour to six hours. From this she will 
awaken without exhaustion, and greatly 
refreshed. The puerperium will be en- 
tirely normal, the flow of milk undisturbed, 
and involution satisfactory. Nausea and 
vomiting are almost unknown, even when 



76 TWILIGHT SLEEP 

chloroform or ether have been used, be- 
cause the quantity required will have been 
so small. Headache will occasionally be 
noted, but this too will rarely cause an- 
noyance. The only post-partum complica- 
tion that I noted was an annoying herpetic 
eruption of the mouth and throat, from 
which a very few cases suffered. This I 
believe can be entirely avoided by giving 
water freely. In successful cases the 
mother will be less exhausted and will 
more rapidly regain her strength than in 
cases where scopolamine has not been used. 
From this point on no complications will 
arise in mother or child in any way ascrib- 
able to Twilight Sleep. 

Though this treatment is used at Frei- 
burg only in the hospital, there is no rea- 
son why it cannot be carried out in the 
home. It simply requires the dark, quiet 
room, the usual paraphernalia, the exclu- 
sion of all members of the family and 
friends, and the constant presence of the 



TWILIGHT SLEEP 77 

obstetrician with, plenty of assistants. 
The only absolute contra-indication to 
the use of Twilight Sleep is primary in- 
ertia. Contracted pelvis, dry labors, rigid 
cervix, eclampsia, cardiac disease are not 
contra-indications. In the higher degrees 
of contracted pelvis operative interfer- 
ence will have been arranged for before 
the injections are started. 



in 



CONTROVERSY BETWEEN FKEIBUKG AND BERLIN 

The controversy between Freiburg and 
Berlin became so prominent because of the 
vast difference of opinion between two such 
important clinics as those of Kroenig and 
Bumm. Possibly Twilight Sleep would 
have been generally adopted as a result of 
Gauss's favorable report, had it not been 
that Bumm's Berlin Clinic, then the fore- 
most in Germany, so soon after expressed 
such an opposite view of the entire matter. 
The controversy was simply an inter- 
change of opinions as to the value of scopo- 
lamine and morphine administered in com- 
bination during active labor, and as to the 
method, dosage and technique of adminis- 
tration. Gauss's original article, with the 
report of 300 cases, was more detailed and 
78 



TWILIGHT SLEEP 79 

more exact, more scientific and above all 
much more enthusiastic than anything that 
had gone before. Because it had developed 
a definite technique based on certain scien- 
tific tests, it was the very beginning of the 
modern view of Twilight Sleep. Following 
the courageous lead of von Steinbuchel, 
others had experimented with scopolamine 
and morphine in labor, but only with the 
hope of producing analgesia. Gauss prac- 
tically started where Steinbuchel left off. 
He developed the method of administering 
small doses, repeated as frequently as re- 
quired, to keep the patient in a state in 
which there was loss of memory for pass- 
ing events. 

Gauss's enthusiastic article in 1906 was 
soon followed by Hocheisen's unfavorable 
report. Gauss answered the criticisms of 
his method which, it will be remembered, 
Hocheisen had so entirely disregarded. 
At this time, and as a part answer, Gauss 
reported in detail his first 1,000 deliveries 



80 TWILIGHT SLEEP 

with scopolamine and morphine. It is not 
necessary to review this report at length, 
for it only showed, as was to be expected, 
that Gauss's new statistics merely im- 
proved upon his original work. He dis- 
cussed the reasons for Hocheisen's fail- 
ures, showing that, though some of them 
were due to the poor solutions used, 
the greatest trouble came from not having 
followed the rules that Gauss had deduced 
from his own painstaking work. 

After reading the reports of both Hoch- 
eisen and Gauss, we must feel that the 
latter 's work was much more thorough and 
careful than that of the former. In the 
first place Gauss reports many more cases, 
and practically all of them were conducted 
under his supervision, while Hocheisen 
saw only forty of the 100 cases he reports, 
and these forty with an eye to analgesia 
rather than to amnesia. Gauss concludes 
his article in which he reported the 1,000 
cases with details of his last 500 cases. 



TWILIGHT SLEEP 81 

One mother died following operative 
bleeding in a deformed pelvis. Twenty- 
three of the mothers had a definite cardiac 
condition, which, according to Gauss, was 
helped by the treatment. This was in di- 
rect contradiction to the observations of 
Hocheisen and Steffen. Gauss measured 
the post-partum bleeding in 363 cases and 
found that in 92.8% it was entirely physio- 
logical, in 6.3% it was less, and in only .9% 
was it above the normal. In no case did it 
threaten life. The third stage was not ef- 
fected, and in only 1.7% of the 1,000 cases 
was there a subsequent morbidity. In his 
first 500 cases he had used forceps in9.68%, 
but in the latter 500 this was found neces- 
sary in only 4.95%. The oligopnea de- 
creased to 12.7% and the asphyxia to 
6.3%. The fact that there were 3% less 
fetal deaths than in non-Twilight cases is 
explained by Aschoff, of Freiburg, on the 
ground that the slightly delayed breath- 
ing worked favorably, by preventing inspi- 



82 TWILIGHT SLEEP 

ration before the head was fully born, thus 
preventing aspiration of fluids. Gauss 
concludes his article with the repetition of 
the rules he had before laid down, and em- 
phasizes the value of the memory test, say- 
ing, "On the proper use of this test 
depends the success of the method." Hoch- 
eisen reported no further cases. He did, 
however, attempt to answer Gauss, and in 
a discussion on Twilight Sleep, in Munich, 
he reiterated the views he had previously 
expressed. 

Steffen strongly supported Hocheisen, 
but the report which he published for the 
purpose of casting discredit on Gauss's 
work proves, it seems, rather that Gauss 
developed the best results through his un- 
tiring efforts and adhering strictly to his 
own technique, which the others had ig- 
nored. It will be remembered that Steffen 
gave two-thirds of his cases only one in- 
jection, and yet he gives one the impres- 
sion of actually doubting Gauss's figures, 



TWILIGHT SLEEP 83 

possibly believing that it was enthusiasm 
that had led Gauss to favorable observa- 
tions, where an unbiased observer would 
have reached other conclusions. 

Despite further enthusiastic articles by 
Gauss and Kroenig and favorable reports 
from various parts of the Continent, as 
well as a few from England and America, 
the method did not come into general use. 
This may be explained partly by the fact 
that Twilight Sleep requires much time 
and attention on the part of the obstetri- 
cian and his assistants, and surroundings 
that are very difficult to obtain in large in- 
stitutions. But the fact that Twilight 
Sleep was not more widely adopted must 
be ascribed chiefly to the unfavorable re- 
ports of Hocheisen and Steffen. Hochei- 
sen was virtually speaking for his chief, 
Prof. Bumm, who was then in charge of 
the Frauenklinik at the Charite in Berlin, 
and was generally recognized as Ger- 
many's foremost obstetrician. Gauss and 



84 TWILIGHT SLEEP 

Kroenig had so much faith in their own 
conclusions that they were not hindered 
by this antagonism, and continued their 
technique, so that up to the present writing 
they have had over 6,000 successful Twi- 
light cases. 

In the tenth edition of Bumm's "Grun- 
driss zum Studium der Geburtshilf e, ' ' 
he says in regard to this matter: "Be- 
cently there has again been used the sub- 
cutaneous injection of narcotics in the 
form of a combination of scopolamine and 
morphine, whereby, as has been shown by 
Gauss through many observations at the 
Freiburg clinic for women, there can be 
produced for many hours during labor a 
sort of Twilight Sleep, so that the con- 
scious sensation of pain almost disappears 
and there remains for the woman only 
slight memory of the course of the labor. 
Everything depends on the correct dosage. 
The treatment begins when the pains are 
pronouncedly strong and regular, with 



TWILIGHT SLEEP 85 

morphine 0.01 (gr. 1/6) and scopolamine 
0.0003 (gr. 1/200). By means of repeated 
injections of scopolamine 0.0002 to 0.0001 
(gr. 1/200 to 1/600), which are given ac- 
cording to the condition of the woman, the 
Twilight Sleep is brought about and main- 
tained. Too strong doses can produce a 
diminution in the strength of the pains, or 
their entire cessation, and thereby delay 
the labor hours or days. The method re- 
quires not only much practice and experi- 
ence on the part of the doctor, but can only 
be undertaken when the doctor can contin- 
uously remain near the patient. It is con- 
tra-indicated in abnormal labor conditions 
and diseases of the woman. Since the chil- 
dren are not infrequently born in a condi- 
tion of somnolence, in which the breathing 
is delayed or stops entirely, they, too, re- 
quire careful watching.' ' 



IV 



CHEMTSTEY AND PHARMACOLOGY OP SCOPO- 
LAMINE 

Every phase of the action of morphine is 
too well known to all practitioners to re- 
quire discussion here. There has always 
been so much controversy over scopolam- 
ine and hyo seine that a few words re- 
garding these drugs will be timely. 

Though the last edition of the United 
States Pharmacopoeia considers hyoscine 
and scopolamine identical, many text- 
books on materia medica claim that hyos- 
cine is dextrorotatory, and therefore less 
powerful and less reliable than scopolam- 
ine, which is levorotatory. They are gen- 
erally known as belonging to the bella- 
donna or atropine group. Scopolamine is 
86 



TWILIGHT SLEEP 87 

an alkaloid obtained from a number of dif- 
ferent plants, the most common of which 
are Hyoscyamus albus and Hyoscyamus 
nigra and Scopolia carnioca. Scopolamine 
is slightly soluble in water. The hydrobro- 
mide salt, which is the form generally 
used, crystallizes in rhomboids, which are 
likewise soluble in water and alcohol, spar- 
ingly soluble in chloroform, and insoluble 
in ether. It has a bitter, acrid taste and is 
acid to litmus. It is slightly efflorescent 
and when ignited leaves no residue. 

It is very difficult to isolate scopolamine, 
and some of the early variable results with 
the use of the drug may have been due to 
impurities from which it had not been en- 
tirely separated. Though Eeichardt and 
Hohn discovered the drug in 1871, it was 
not until much later that scopolamine 
and hyoscine were proven to be identi- 
cal. 

The preparations now on the market all 
presumably comply with the standards of 



88 TWILIGHT SLEEP 

purity of our United States Pharmacopoeia. 
The purity can be tested as follows : Add 
sulphuric acid and, if there are no carbon- 
izable impurities present, the solution will 
remain colorless. The absence of mor- 
phine is proven when the subsequent addi- 
tion of a drop of nitric acid likewise pro- 
duces no color. The chemical formula is 
C 17 H 21 N0 4 . 

Scopolamine dilates the pupil more rap- 
idly than does atropine, but its effects in 
this direction seem to be short-lived. The 
heart, and therefore the pulse, are slow, 
as is the respiration. It produces sleep 
by numbing the sensory areas in the brain. 
Few sensory impressions are received, 
consciousness is lessened and hence sleep 
produced. In fact, the action on the entire 
brain, in the average case, as well as on the 
entire system, is what is ordinarily termed 
' ' depressing. ' ' In rare cases it causes diz- 
ziness, restlessness, excitation and possibly 
delirium. It is excreted by the kidneys 



TWILIGHT SLEEP 89 

and found in the urine, but all trace of it 
disappears from the system in twelve 
hours. Over-dosage shows itself in ex- 
treme dryness of the mouth and throat, di- 
lated pupils, dry red skin, rapid pulse and 
breathing, a wild, talkative delirium and 
extreme restlessness. It is generally ad- 
ministered hypodermically, the usual dose 
being from 0.0003 (gr. 1/200) to twice that 
amount. In obstetric practice smaller 
doses are given and repeated when neces- 
sary. 

Gertrude Slawyk, who wrote her medical 
thesis at Freiburg in 1912, on the chem- 
istry and pharmacology of scopolamine, 
claims that scopolamine quiets the cerebral 
centers so that in about ten minutes after 
hypodermic administration there are 
drowsiness, heaviness of the eyelids, semi- 
unconsciousness and then sleep. It may 
cause dizziness, rarely nausea, itching, sen- 
sation of warmth, reddening of the face 
and a sour taste ; and when large doses are 



90 TWILIGHT SLEEP 

given it may cause delirium. The sleep 
produced is deep and quiet. It is difficult 
to awaken the patients and more difficult to 
rouse them to complete consciousness. 
The deepest sleep is supposedly in the first 
two hours and with it comes the slowing 
of the pulse and respiration. Finally there 
is an almost physiological sleep, lasting 
from six to ten hours, from which the pa- 
tient awakes slightly benumbed but rested. 
Slawyk does not discuss the condition of 
the eyes. She says the circulation is mod- 
erately slowed, but otherwise not altered, 
the blood pressure is temporarily raised 
and the respiration slowed. The kidneys 
do the work of excretion, but some of the 
drug traverses the placenta and affects 
the child in utero. The gastro-intestinal 
tract suffers only a diminution of secre- 
tion. Eepeated large doses of scopolamine, 
greater than have ever been used in obstet- 
rics but which may be employed in neuro- 
logical conditions, may cause cacosia. It is 



TWILIGHT SLEEP 91 

impossible to state the exact toxic dose, as 
the individual's reaction to the drag is 
most variable. Though large doses of it 
may be poisonous, it is certainly safe when 
used in the small doses required in ob- 
stetrics. 

All earlier writers mentioned the fact 
that the drug rapidly deteriorates, and it 
remained for Straub, also of Freiburg, to 
make a stable solution of the preparation. 
He discovered that mannit, a sugar of the 
sixth degree, acted as a preservative for 
scopolamine and that a 10% alcoholic solu- 
tion of mannit was the most convenient 
form for the purpose. In this solution the 
drug remains therapeutically active over a 
period of years. 

Eecently Lieb, of Columbia University, 
stated that scopolamine is found in the 
mother's milk for several days after ad- 
ministration, but the author has not been 
able to find any confirmation of this state- 
ment. The retinal signs in the infant due 



92 TWILIGHT SLEEP 

to the scopolamine pass away more rapidly 
than would be the case if the baby were 
continuing to get scopolamine with its 
milk. 



FURTHER REVIEW OF THE LITERATURE WITH 

SPECIAL REFERENCE TO TWILIGHT 

SLEEP IN ENGLAND 

In Great Britain, as elsewhere, scopolam- 
ine and morphine were used in obstetrics 
by various observers shortly after the ap- 
pearance of the original work of Kroenig 
and Gauss. Despite the fact that these ob- 
servers were thoroughly familiar with the 
German work, as shown by their own writ- 
ings, not one of them seems to have scru- 
pulously followed the Freiburg technique. 
Buist, of Dundee, reviewed the work of 
Gauss and other Germans in great detail 
in an article published in 1907, and con- 
cluded from his own observations in sixty- 
five cases that though there is the risk that 
the procedure may prove annoying in indi- 
93 



94 TWILIGHT SLEEP 

vidual cases, the picture is a very satisfac- 
tory one. In most cases alleviation of pain 
was achieved. In one case where the labor 
seemed to have been stopped by the drug, 
though the patient slept all night, the os 
was entirely dilated by morning. He does 
not believe that the treatment can be held 
responsible for any cases of atonic bleed- 
ing. He believes that though over-dosage 
produces possible dangers this can be 
avoided by careful watching. 

Corbett reported twenty cases. He 
seems to have confounded amnesia with 
analgesia. He used larger doses than 
Gauss recommended, and combined the 
scopolamine and morphine with other 
drugs. The memory test was not used by 
him, and his deductions though interesting 
are of little value regarding Twilight Sleep 
as we now understand it. He draws the 
following six conclusions: 

1. Scopolamine and morphine are of 
great use in cases of hysteria in the first 



TWILIGHT SLEEP 95 

stage, but should be avoided in the second 
stage when possible. 

2. There were no ill effects to the mother 
from repeated doses. 

3. There were no ill effects to the child 
from repeated doses, provided the child 
was not born until at least four hours after 
the last injection. 

4. Apnea is due to the morphine. 

5. The apnea is best overcome by hot 
baths. 

6. Strychnia may help in counteracting 
the ill effects of the drugs. 

Cotterill, who has been quoted in some 
of the later literature on this subject, does 
not, as far as can be ascertained, mention 
the use of these drugs in obstetrics. He 
limits his remarks to a discussion of re- 
peated injections given previous to surgi- 
cal operations. 

Croom, who in 1908 reported sixty-two 
cases, wandered far from the Freiburg 
technique and tried almost entirely for 



96 TWILIGHT SLEEP 

analgesia. He came to the conclusion that 
the treatment acted (1) as a soporific, (2) 
as a narcotic, leading in some cases to com- 
plete anesthesia, and (3) as a possible am- 
nesic. In the discussion of this report Hat- 
tain and Ferguson claimed to have been 
using the drugs for about eighteen months, 
with satisfactory results, but they gave no 
details. 

Innes, in 1912, said that he had been 
using the drugs for two years, and found 
them "most efficient in soothing the pains 
of labor, ' ' but he came to the rather pecu- 
liar conclusion that only one dose should 
be used, stating that if beneficial results 
were not obtained thereby, further injec- 
tions were useless, as well as dangerous; 
useless because a patient who was not 
helped by the primary injection showed 
that her system could not be properly in- 
fluenced, and dangerous because repeated 
injections might injure the child. 

Giuseppi, in a lengthy article in The 



TWILIGHT SLEEP 97 

Practitioner for 1911, reports that in six 
cases he used hyoscine gr. 1/100, morphine 
gr. 1/4, and atropine gr. 1/150. In ten 
cases he reduced the morphine to gr. 1/6, 
and the atropine to gr. 1/180. In twenty- 
one cases he again gave morphine gr. 1/4 
and omitted the atropine. He tried very 
hard to individualize his cases and he re- 
peated the hyoscine when he considered it 
indicated, but he never gave more than one 
dose of morphine. The dosage of hyoscine 
was much larger than Gauss advised, and 
instead of using the memory test to decide 
the need of repeated doses he waited until 
he saw that the patient was awakening. 
He says that he attempted to produce, not 
unconsciousness, but a Twilight Sleep, 
from which the patient could be awakened 
at any moment without recollection of 
what had occurred in the meantime. In six 
(16.2%) of his thirty-seven cases analgesia 
was complete ; in ten (27% ) it was marked ; 
in fourteen (37.8%) it was decreased, and 



98 TWILIGHT SLEEP 

in seven (19%) there was none. One of 
these last seven cases was very excited be- 
fore treatment began and remained so even 
after two injections. In two of these seven 
delivery was too rapid for the treatment to 
be of any valne. He states that seven of 
the patients did not know of the birth of 
the child. Eleven multipara claimed that 
they had very much less pain than in their 
previous labors. In one case a partially 
adherent placenta was manually removed 
without any anesthetic and with very little 
discomfort. In several cases of perineal 
suture there was little or no pain. Twen- 
ty-nine of his cases slept between contrac- 
tions; four became excited. There was 
flushing of the face in almost every case 
and there was frequently dilatation of the 
pupils. He noted no severe thirst and no 
change in the maternal pulse. He states 
that the difficulty in measuring uterine 
contractions accounts for the difference in 
the views as to how these are influenced by 



TWILIGHT SLEEP 99 

Twilight Sleep. The woman, he says, cer- 
tainly does not bear down as strongly as 
normally, probably on account of drowsi- 
ness and diminished reflex action. The 
third stage he did not find altered. Six 
of his children were born in what he terms 
"a slight condition of blue asphyxia." 
Two of them could not be revived. In one 
of these the fetal heart was faint through- 
out labor and in the other the membranes 
had been ruptured twenty-seven hours be- 
fore birth. In four other cases, the fetal 
heart was found on auscultation during la- 
bor to be weak or irregular. Forceps were 
immediately applied, but two of the chil- 
dren were born dead. The after-effects on 
all the mothers were entirely satisfactory, 
and he noticed no later effects on the child. 
He reached the following conclusions : 

1. The result to be obtained is amnesia. 

2. That it is an efficient means of con- 
trolling pains and practically safe when 
proper precautions are taken. 



100 TWILIGHT SLEEP 

3. There is danger to the child unless the 
fetal heart is carefully watched. 

4. The course of labor is not altered. 

* 5. The repetitions of the injections must 
be regulated by the amount of suffering. 

6. The morphine should never be re- 
peated. 

7. Solutions must be freshly prepared. 

t 8. The dosage is hyo seine hydrobromide 
gr. 1/100 and morphine sulphate gr. 1/4. 
Solomons and Freeland, working at the 
Botunda, in Dublin, tried the procedure in 
100 selected cases of primiparae. The 
treatment was started with scopolamine 
gr. 1/500 and morphine gr. 1/4. After 
the earlier cases they used scopolamine 
gr. 1/120 and morphine gr. 1/6. They se- 
cured complete analgesia in ten, marked in 
fifty-seven, fair in twenty and no analgesia 

* We are now all convinced that the repetition of the 
drug must depend on the memory test alone, provided 
the mother and baby are doing well. 

f Everyone to-day would consider this too much 
hyoscine. 



TWILIGHT SLEEP 101 

in thirteen. Of these last, fonr vomited 
the medicine and eight received too small a 
dose. They did not try for amnesia and 
they did not believe it necessary to keep 
the patient in a dark, qniet room. They 
found that labor was prolonged, but there 
was no danger to mother or child, and that 
it was safer to give the drug by mouth. 

Before the British Association of Eegis- 
tered Medical Women, Constance Long re- 
ported on fifteen selected cases, and con- 
cluded from these that the method was 
safe for both mother and child. In 
the discussion following this report, Mrs. 
Meakin Haarbleiden told of her visit to 
Freiburg and of the favorable impression 
received. 

Dr. Spencer Shill, in 1910, reported nine- 
teen cases and said that these had given 
him great satisfaction. Though much en- 
couraged he was not yet prepared to give 
definite information on its safety and 
value. During the discussion Prof. Albert 



102 TWILIGHT SLEEP 

Smith reported one case with complete an- 
algesia. 

Halpern and Brooman, in 1909, reported 
100 cases from Winnipeg. They reviewed 
the continental work and also some animal 
experiments. They were very well satis- 
fied with the procedure, and fonnd that it 
produced amnesia and analgesia without 
delaying the labor or causing any danger 
to mother or child, but that it required 
hospital care and detailed watching. 

Before the Obstetrical and Gynecologi- 
cal Section of the Eleventh Congress of 
Russian Physicians, Iljin reported sixty- 
seven cases, and said that the treatment 
produced painlessness, with only a slight 
lengthening of labor and very little dan- 
ger. Brodsky, of Moscow, reported 200 
cases; Trabscha forty; and Nejelow sixty; 
but the details of their work do not appear 
in the literature. 

The study of the above certainly shows 
that most of the men working outside of 



TWILIGHT SLEEP 103 

Germany were giving scopolamine and 
morphine and obtaining satisfactory re- 
sults, but were in general not giving Twi- 
light Sleep according to the Freiburg tech- 
nique. Giuseppi was the only one who 
tried to obtain amnesia, and he did not use 
the memory test as a guide for repeating 
the injections. The others were satisfied 
with more or less analgesia. 



VI 



TWILIGHT SLEEP IN AMEKICA AND KESULTS OF 
A QTJESTIONNAIKE 

Shoetly after Gauss 's original work ap- 
peared, Newell, of Boston, reported before 
the American Gynecological Society his in- 
vestigation of Twilight Sleep in 123 cases. 
He finally gave np the method, fearing that 
it possessed certain inherent dangers, and 
because too many of the babies were born 
asphyxiated. He did not adhere to the 
Freiburg technique. McPherson also used 
Twilight Sleep at that time, but abandoned 
it after a short trial. Both of these men 
have within the last year again experi- 
mented with the method. 

In connection with these reports must be 
mentioned the work of Butler, who in 1907 
gave a very extensive review of the entire 
104 



TWILIGHT SLEEP 105 

subject. Most of his work dealt with 
scopolamine in surgery rather than in ob- 
stetrics. He reported no cases of his own. 
At the same time Birchmore, of Brooklyn, 
used hyoscine gr. 1/100, morphine gr. 
1/4 with cactine. He did not use the Frei- 
burg method and tried only to quiet the 
pains. He found that this combination 
" stripped motherhood of its horrors.' ' He 
seems to have been very successful in pro- 
ducing analgesia without doing any harm, 
and has recently stated that he still uses 
this method. 

Since the summer of 1914 there has been, 
here in America, a great revival of interest 
in this subject, and the literature on Twi- 
light Sleep is continually growing. It 
seems to me unfortunate that all of the 
present investigators are not adhering to 
the Freiburg method in every detail. This 
may be accounted for in several ways. 
American hospitals are not as well sup- 
plied with trained midwives and resident 



106 TWILIGHT SLEEP 

physicians as are the European clinics. 
Furthermore, not all streets on which hos- 
pitals are located are as noiseless as Al- 
brecht Strasse, where the Freiburg Frau- 
enklinik is located. And, probably, most 
important of all, we are not able to have 
our Kroenigs ten minutes away from the 
institutions and our Gausses living in them. 
Hence it may become necessary to adopt a 
method which is less difficult of manipula- 
tion, even if less successful, for alleviating 
the pains of childbirth, than the Freiburg 
method. Nevertheless, we should make 
every effort to attain the successes of Frei- 
burg along the lines advised by the masters 
at that place. In other words, we should 
try to obtain amnesic deliveries with or 
without analgesia, and we should use the 
memory test to decide the necessity of suc- 
cessive small doses of scopolamine. 

In September, 1914, Arluck and Eongy 
reported 100 cases, obtaining 83% am- 
nesia, 8% analgesia and 9% failures. 



TWILIGHT SLEEP 107 

They concluded that such a method, which 
instils confidence in the patients, is worthy 
of and must be given a fair trial. 

In the October, 1914. American Journal 
of Obstetrics, Rongy further discusses the 
topic, adding twenty-five cases, and con- 
cludes : 

1. Standard solutions are essential. 

2. Cases must be individualized. 

3. The patient must not be disturbed. 

4. A nurse or physician must be in con- 
stant attendance. 

5. The method should be applicable in 
well-regulated private homes as well as in 
hospitals. 

6. It does not affect the first stage of la- 
bor, but the second stage is somewhat pro- 
longed. 

7. Pain is markedly diminished in all 
cases. Amnesia is present in the greatest 
number. 

8. The treatment does not interfere with 
other therapeutic measures. 



108 TWILIGHT SLEEP 

9. The fetal heart sounds must be fre- 
quently watched. 

10. Oligopnea was present in 15.2% of 
cases. It caused no permanent ill effects. 

11. The puerperium was not affected. 
In the same issue Harrar and McPher- 

son report 100 cases from the Lying-in 
Hospital of New York, and conclude that 
it is a valuable method of causing amnesia 
in from 60% to 70% of cases, and that it is 
safe in painstaking hands when the pre- 
scribed technique is followed. 

The same magazine for December has a 
detailed article by Knipe. He reviews the 
literature, gives the details of the tech- 
nique and dosage and reports his own ex- 
periences in forty-one cases. Knipe very 
enthusiastically and strongly favors the 
general adoption of the treatment. 

Polak, in the Long Island Medical Jour- 
nal of December, 1914, reports fifty-one 
cases, and says : "From our observations, 
both here and abroad, there is no reason 



TWILIGHT SLEEP 109 

why Dammerschlaf should not be given to 
all women who showed the physical signs 
of active labor, provided that the woman 
is under continuous and intelligent obser- 
vation." In the same journal Humpstone 
concludes from twenty cases that Twilight 
Sleep is a scientific possibility in 90% of 
cases, but it requires a hospital and a spe- 
cialist, and those who wish to use it must 
study under those who are already ac- 
quainted with the method. 

In American Medicine of December, 
1914, Hilkowich reports 200 cases from the 
Jewish Maternity Hospital of New York, 
some of which had already been reported 
by Eongy. He, too, strongly approves of 
the method and advises further work with 
this treatment. 

American Medicine for January, 1915, 
contained a symposium of articles on this 
subject by the following men of Greater 
New York : Wainwright, Brodhead, Knipe, 
Hellman, Boldt, Beach, Waldo, Eongy, 



110 TWILIGHT SLEEP 

Heller and Bandler. Brodhead reports 
twenty- one cases, in which he and Stein 
used the Siegel method. Knipe added one 
case to his series and Beach reported fifty 
cases. All except Bandler are more or less 
enthusiastic about the method. Another 
article by Knipe, in The Modern Hospital, 
added nothing new to his previous reports. 
The February, 1915, American Medicine 
contains an article on the subject by F. 
W. Whitney. He adds spartein to the 
other drugs, with very favorable results. 
This addition of spartein is unnecessary. 
Late in January, 1915, there was a dis- 
cussion on Twilight Sleep under the aus- 
pices of the Chicago Medical Society. Po- 
lak there reported 175 cases, and con- 
cluded that the method is primarily a first- 
stage procedure, that it lessens operative 
interference, that it can be used without 
danger, but should be employed only in 
hospitals. Schloessingk, of Freiburg, with- 
out giving details, also spoke in favor of 



TWILIGHT SLEEP 111 

the method. Frankenthal and Baer re- 
ported thirty-nine cases with the following 
results : Thirteen no success, five very lit- 
tle, seven partial, four fair, seven good, 
and three where the success was complete. 
Wakefield, of San Francisco, at this meet- 
ing reported forty cases, and is convinced 
of the tremendous value of the procedure, 
and says that he would as soon consider 
performing a surgical operation without 
an anesthetic as conducting a labor with- 
out scopolamine amnesia. He has dis- 
carded the memory test and simply uses 
his general observations of the patient. 
He says : " When the patient's expression 
begins to take on a keen look, like a child 
awakening from sleep, she was endeavor- 
ing to place herself and find her conscious- 
ness ; when, furthermore, she begins to suc- 
cessfully correlate happenings, then she 
needs another dose." 

Mosher has written an article in The 
Kansas State Journal, and another in Sur- 



112 TWILIGHT SLEEP 

gery, Gynecology and Obstetrics. He tells 
of his visits to various institutions in the 
East where the method is in use, and adds 
four cases of his own. 

Scadron reports 202 cases in the Inter 
State Medical Journal. Most of these 
cases had been reported elsewhere in the 
literature. 

Philip J. Carter, in the January, 1915, 
New Orleans Medical and Surgical Jour- 
nal, reviews the literature briefly, but adds 
no case of his own. 

At the January meeting of the Gyneco- 
logical Section of the New York Academy 
of Medicine, there was a special discussion 
on Twilight Sleep, in which fifteen mem- 
bers took part, all but one being more or 
less in favor of this treatment. 

The Medical Times for December, 1914, 
had remarks by ten men interested in this 
work. These were not scientific discus- 
sions, simply short paragraphs containing 
expressions of opinion, and without case 



TWILIGHT SLEEP 113 

reports. Polak, Knipe and Schloessingk 
were most enthusiastic, whereas DeLee 
says that the drags have inherent dangers 
and will cause unfortunate experiences. 
He claims that even in the hands of spe- 
cialists there will be infant deaths and in- 
jured mothers. Hirst says that after try- 
ing the method when it was first recom- 
mended, and again more recently, he has 
given it up. Bell, Gellhorn, Applegate, 
Zinker and Bovee feel that it has a limited 
field, and should be used only in hospitals, 
and by specialists with plenty of assistants 
and correct technique. 

Beach, before the Gynecological Section 
of the New York Academy of Medicine, 
compared 1,000 cases of scopolamine la- 
bors, collected from various sources, in- 
cluding some of his own, with 1,000 non- 
scopolamine labors at the Jewish Hospital 
in Brooklyn. The results greatly favored 
the scopolamine cases. In the discussion 
following his paper, Brodhead and Polak 



114 TWILIGHT SLEEP 

spoke in favor of Twilight Sleep, Vineburg 
and Kosmak against it. Bongy, who pre- 
viously had been a supporter of the 
method, spoke rather against it. He laid 
great stress on the fact that he had fre- 
quently seen persistent headache follow 
the treatment, and stated that the use of 
the drugs constitutes a definite danger to 
the baby. Brodhead mentioned that he 
had had 110 cases to date, and had seen no 
harm since he had replaced the Siegel 
method with Gauss's technique. 

Leavitt, in The American Journal of 
Clinical Medicine for April, 1915, reports 
ten successful cases, in which he used mor- 
phine, hyoscine and cactine tablets. He 
says, " Twilight Sleep should not be ad- 
ministered at random,' ' that the dose of 
hyoscine and morphine should be given 
cautiously and in minimum amounts, that 
the subject under its influence should be 
closely watched by an experienced attend- 
ant, and lastly, that all the other advan- 



TWILIGHT SLEEP 115 

tages of environment and suggestion 
should be employed. 

N. G. Green, who reported in the Jour- 
nal of the Medical Society for New Jersey, 
January, 1915, had twenty cases. There 
was analgesia in all of them. Sixteen were 
somnifacient, ten had complete amnesia, 
five partial, and five slight amnesia. There 
were three forceps cases and two cases of 
pisiotomy. There was one case of nephritis 
with gastric irritation ; the baby died three 
days later, with signs of subdural hemor- 
rhage from a prolonged second stage, rath- 
er than from the two injections the mother 
had received. The majority of the babies 
were born in a semi-narcotic condition, 
which passed away without interference in 
about twenty minutes. In one, cyanosis 
persisted for twelve hours. After the deliv- 
ery the mothers seemed rather exhilarated 
by the drugs than shocked by the labor, 
and the puerperium was unaffected. 

C. E. Dakin, reporting in the Iowa State 



116 TWILIGHT SLEEP 

Medical Society Journal for March, 1915, 
admits the need of producing analgesia in 
a certain number of labor cases. He tried 
hyoscine, morphine and cactine tablets, but 
found that there were so many asphyxiated 
babies and unpleasant results that he dis- 
carded the treatment. 

Eongy, in his latest paper, read before 
the New York State Medical Society late 
in April, 1915, again speaks enthusiasti- 
cally for Twilight Sleep, but lays emphasis 
on the fact that it is amnesia that is pro- 
duced and not an absence of pain. 

Gardiner, in the Ohio State Journal for 
April, gives a report of twenty cases from 
private practice, and says: "Experience 
with this technique leads the writer to the 
conclusion that in properly selected cases 
the memory of the event is obliterated and 
the pain and shock of childbirth reduced to 
a minimum." 

The Journal of the American Medical 
Association for May 22, 1915, contains two 



TWILIGHT SLEEP 117 

articles on Twilight Sleep, one by J. L. 
Baer, of Chicago, and one by W. E. Libby, 
of San Francisco. Baer reports sixty 
cases, and summarizes: "The prolonga- 
tion of labor, the increase in the number 
of fetal asphyxias, the excessive thirst and 
intense headaches that are so distressing, 
the difficult control of patients and avoid- 
ance of infection by soiling the genitals, 
the more frequent post-partum hemor- 
rhages, the blurred vision, the ghastly de- 
liriums persisting far into the puerperium, 
the inability to recognize the onset of the 
second stage unless by risk of more fre- 
quent examinations, the masking of early 
symptoms, such as ante-par turn hemor- 
rhage, rupture of the uterus and even 
eclampsia, the violence and uncertainty of 
the whole treatment, the general bad im- 
pression given to our patients who are be- 
ing taught to approach the horrors of la- 
bor in fear and trembling, constitute so 
severe an arraignment of this treatment of 



118 TWILIGHT SLEEP 

labor cases that we feel compelled to con- 
demn it, leaving open the question of the 
merits of a single dose of morphine and 
scopolamine in those cases in which we 
have hitherto given morphine and atro- 
pine.' ' 

Libby reports thirty-five cases, and 
says: "Physicians must recognize that 
the method has not reached the perfection 
which warrants indiscriminate use," and 
concludes : ' ' The very satisfactory results 
in the majority of cases provides the stim- 
ulus to secure further improvements in the 
method which will broaden its field of ap- 
plication and remove its objectionable ef- 
fect upon the new-born infant. ' ' 

As can be seen from a study of this enor- 
mous mass of literature, Twilight Sleep is 
being tested all over the country, and those 
who have adhered faithfully to the Frei- 
burg technique seem to be favorably im- 
pressed with its possibilities. 

To get a clearer view of the position of 



TWILIGHT SLEEP 119 

the profession on Twilight Sleep, about 
one hundred and twenty letters, containing 
a series of questions, were mailed to all 
Fellows of the American College of Sur- 
geons who in the last year-book of that 
organization had signified their interest in 
obstetrics. Fifty answers were received. 
These came from all parts of the country 
and should be of some interest if reviewed 
in detail, though they prove little. Medi- 
cal conservatism has caused all obstetri- 
cians to be guarded in their statements 
about a procedure that has received so 
much lay notoriety, but the majority ex- 
press their belief that a perfected and safe 
painless childbirth would be of incalculable 
value. The questions were answered as 
follows : 

1. Have you tried Twilight Sleep accord- 
ing to the scopolamine-morphine method of 
Freiburg? Twenty-six answered in the af- 
firmative. 

2. If so, in how many cases! The an- 



120 TWILIGHT SLEEP 

swers gave figures from one to 250 
cases. 

3. Have you any intention of using this 
method in the future? Three of the men 
who had used it in a few cases did not think 
they would go further in their experi- 
ments. Two were in doubt. The other 
twenty-one who were using it were going 
to continue. Two of those who had not 
used it intended to try it. 

4. Do you use any drug or method for 
allaying the pains of labor? Practically 
all answered yes, showing the need of some 
treatment, and that the suffering of labor 
is not entirely physiological. At times it 
requires alleviation. 

5. If so, what drug or method? Mor- 
phine, ether, chloroform, chloral, antipy- 
rine, nitrous oxide were all mentioned in 
answering this question. 

6. Have you found any prolongation of 
the first stage of labor? If so, how much? 
This was answered as follows: Six said 



TWILIGHT SLEEP 121 

it prolonged it; ten said it did not; two 
said it shortened this stage. The question 
was unanswered eight times. One man 
found it prolonged as much as 30% to 50%, 
and another said that no case was fully 
dilated in less than thirty-six hours. 

7. Have you found any prolongation of 
the second stage of labor? If so, how 
much? Eighteen answered that it was 
lengthened, three of these say the length- 
ening was but slight. Six left this unan- 
swered, and two thought it was not length- 
ened. My own views being that it was only 
lengthened after the head reaches the 
perineum. 

8. Have you found any harm to the 
mother? (a) During labor? Fifteen found 
none ; five thought there was harm, and six 
left this unanswered. The harm noted was 
that due to the need of early operative in- 
terference (forceps) ; the increased relaxa- 
tion of the uterus; delirium at times, (b) 
During the puerperium? None who an- 



122 TWILIGHT SLEEP 

swered this saw any harm during this 
stage. 

9. Have you noted any harm to the 
mother's mentality 1 This was invariably 
answered in the negative, though some 
noted the temporary delirium which is oc- 
casionally met. 

10. Have you noted any harm to the flow 
of milk? One man said he thought lacta- 
tion was delayed. Another observer had 
seen one case where lactation gradually 
ceased, and the others saw no harm. Some 
believed it was benefited. 

11. Have you noted any harm to the 
baby? This important question unfortu- 
nately remained unanswered by seven of 
the men testing the method. Six of the 
others saw no harm. Oligopnea, asphyxia 
and apnea were complained of, alone or in 
combination, by twelve. Two observers 
had each seen a stillbirth which they 
thought due to prolonged labor, the drugs 
and forceps. One man narrated two deaths 



TWILIGHT SLEEP 123 

on the fifth and eighth days, respectively, 
one a defective with closed fontanelles, and 
both showing hemorrhages suggestive of 
asphyxia. 

12. Do you consider the method applica- 
ble in the home? The answers show that 
it is the general impression that hospital 
conditions are essential; but that when 
these can be produced in the home then 
Twilight Sleep can be used there. 

13. General Remarks. This was vari- 
ously answered, and a few of the replies 
will tend to show the differences of opinion 
at present existing: 

One not using the method says: "No 
one should use morphine-scopolamine un- 
less he has the opportunity to observe its 
use and thoroughly familiarize himself 
with the technique in a hospital of known 
reputation, with obstetricians skilled in its 
application. From what I have read am of 
the opinion the method is far from perfect, 
and is applicable only in selected cases, 



124 TWILIGHT SLEEP 

and in hospital practice. In routine cases 
it seems to me it is attended with too 
many serions complications." 

Another says in part: "My basic ob- 
jection to scopolamine is owing to the fact 
that hyoscine is not a single definite chemi- 
cal compound, bnt belongs to the stereoiso- 
merides, and that among 'hyoscines' it is 
difficult to distinguish the more toxic from 
the less toxic, perhaps impossible, by the 
means hitherto employed.' ' 

Some other answers were: "Am heart- 
ily opposed to ' Twilight Sleep/ It was 
tested out ten years ago and condemned/' 

"Not practicable for general practi- 
tioner. Only practicable in hospitals." 

"In my private practice I have never 
found a patient who has dreaded a second 
confinement simply on account of the pains 
of labor/ ' 

Among the answers to Question 13 of 
those who had used Twilight Sleep were 
the following: "I do not consider Twi- 



TWILIGHT SLEEP 125 

light applicable in the home unless the at- 
tendant is, first, a trained obstetrician; 
and, second, is willing and able to devote 
his whole time to his patient, it may be 
for twelve hours or longer, keeping con- 
stant watch of the fetal heart and ready to 
operate if it shows any marked change. ' ' 

Another says : ' ' My experience with the 
treatment at home is decidedly less than 
that in the hospital, but from my combined 
knowledge in the few cases stated, leads 
me to believe that Twilight is desirable in 
most cases, especially primiparae. ' ' And 
later: "The more one uses the treatment 
the better it works ; the better one is able 
to judge as to dosage, the more favorable 
the results, and the more enthusiastic one 
becomes as to its general benefits." 

Here is an unusual one: "I was unfa- 
vorably impressed with the Twilight Sleep 
treatment in 1907, and consequently ap- 
proached the subject in September, 1914, 
with a prejudiced opinion. Now I am en- 



126 TWILIGHT SLEEP 

thusiastic. I think the reason of failure in 
1907 was because I allowed the treatment 
to be employed by internes in the hospital. 
I now give it my individual attention as 
much as possible. I believe the treatment 
has come to stay. We have much to learn 
about it yet, and no one should undertake 
it unless he is willing to give the time at a 
personal sacrifice to master the details. I 
believe it will result in specializing obstet- 
rics. I can report no unfavorable results 
except temporary." 

Still another says : i ' My limited experi- 
ence leads me to believe that in certain 
selected cases in primiparous women in 
whom the dread of pains is little short of 
an obsession, the advanced assurance that 
their pain will be relieved is a very impor- 
tant feature.' ' 

Another : " I do not consider that Twi- 
light Sleep in any way comes up to the 
statements made concerning it in the lay 
press.' ' 



TWILIGHT SLEEP 127 

And finally one says : * ' These drugs, I 
think, are dangerous; they certainly pro- 
duce asphyxia of the new-born, and in the 
hands of the general practitioner will cer- 
tainly produce much havoc. ' ' 



vn 

SOME THEOKETICAL CONSIDEEATIONS OF TWI- 
LIGHT SLEEP 

Fkom the earliest days of medicine and 
surgery theories of the causation of shock 
and attempts to allay the same have been 
numerous. Crile wrote, in 1913, in an arti- 
cle on "Shock": "Let me at once state 
my principal conclusion, that all forms of 
shock are caused by over-stimulation and 
consequent exhaustion ; that the brain-cells 
show physical changes, corresponding to 
each stage of the cycle of shock, and that 
with each shock-producing agency which I 
have studied there is shown in the brain- 
cells a hyperchromatic stage followed by a 
hypochromatic stage.' ' In this article he 
also states: "Anesthetics and the nar- 
cotics cause neither brain-cell changes nor 
128 



TWILIGHT SLEEP 129 

increased epinephrin output. " In an arti- 
cle on anoci association, he says, " Psychic 
strain may have deleterious effects, ' * and, 
1 ' The use of a local anesthetic is to inter- 
rupt the passage to the brain of traumatic 
stimuli from the field of operation. ' ' 

Though Crile's theories may not seem to 
fit every case, and may not be perfect, they 
certainly are of great value as a working 
formula for the prevention of shock in la- 
bor. If pain and other unpleasant sensa- 
tions ("nocuous influences ,, ) are allowed 
to travel along the sensory nerves so that 
they are eventually perceived by brain- 
cells, causing %perchromatism and then 
%pochromatism and permanent damage 
of the cell, shock is produced. We must at- 
tempt to break this line of connection be- 
tween the shock-producing agent and the 
brain-cell at some place where we will do 
no harm and not interfere with the physio- 
logical progress of labor. The blocking 
agent must not be more dangerous than 



130 TWILIGHT SLEEP 

the shock itself. Sensory depressants ful- 
fill the first condition and the sensory de- 
pressants, scopolamine and morphine, are 
reasonably safe, and act as a mild anes- 
thetic, allaying the susceptibility of the 
brain. By blocking the painful sensations 
and making the mother oblivious to her 
surroundings, and preventing the chro- 
matic changes which lead to the injury 
of the cells, these drugs tend to lessen 
shock. 

Of less importance, but also of interest 
as abstract considerations are the follow- 
ing: The emotion fear, so often present 
during the later months of pregnancy, 
probably has a harmful influence oil 
mother and child. If the mother feels that 
she is not going to face an ordeal, but sim- 
ply going into a sleep during which her 
child will be born, there must be a cheerful 
prenatal influence which should be advan- 
tageous. 

The absence of the fear of labor prom- 



TWILIGHT SLEEP 131 

ises to increase the birth-rate when Twi- 
light Sleep is generally used. We all rec- 
ognize that in a certain proportion of cases 
fear of childbirth has been the determining 
factor in the prevention of conception, or 
the production of abortion. 

Another advantage to be expected from 
Twilight Sleep is the placing of the art of 
obstetrics on a higher and more dignified 
plane. Only the man who is especially 
trained will be able to give the patient this 
treatment, and as he will have to devote 
much more time and give more attention 
to the patient, we can expect to see in these 
cases a decreased percentage of the acci- 
dents that are now caused by the lack of 
this expert care. 

Finally, it may lead to the establishment 
of more well-equipped institutions for the 
care of the parturient woman. In these 
institutions, any reputable physician 
should be allowed to attend his patient, 
and there should always be at hand, in ad- 



132 TWILIGHT SLEEP 

dition to modern equipment and the 
necessary assistants, a skilled resident 
trained in the various methods of painless 
childbirth. 



VIII 

CASE EEPOKTS WITH STATISTICS 

The sudden lay notoriety which Twilight 
Sleep received in the summer of 1914 nat- 
urally made the medical profession in 
America very skeptical. At this time the 
Charite, at Berlin, was still dominated by 
the views of its former chief, Prof. Bumm, 
and the work of his assistant, Hocheisen. 
There it was felt that the method had been 
fully tested, that Freiburg would not show 
the work it was doing, and that there must 
be some inaccuracy in the reports. A visit 
to Freiburg soon dispelled all skepticism, 
and produced an enthusiasm for Dam- 
merschlaf. How it could best be applied 
elsewhere was the problem that remained 
to be solved. 

The number of cases here reported, 
133 



134 TWILIGHT SLEEP 

though not large, should be of value simply 
because they were carefully studied. It is 
important to preface these statistics with 
the statement that with the exception of 
the few cases where operative interference 
became necessary, the deliveries were made 
by the internes, and I was rarely present. 
The dosage was largely regulated by them, 
though I supervised as much as my time 
and the telephone would allow. The ear- 
lier cases received narcophine gr. 1/2, and 
scopolamine gr. 1/150, and occasionally 
the narcophine would be repeated in 
smaller amounts with scopolamine, the lat- 
ter being in succeeding doses about 1/450 
of a grain. Various preparations were 
tried, but the solutions were always freshly 
prepared by our own druggist, and we 
came to the conclusion that Straub's 
method was the best. Toward the end of 
our series we used morphine gr. 1/4 with 
the initial dose of scopolamine. We never 
repeated the morphine. 



TWILIGHT SLEEP 135 

We admitted to the obstetrical wards at 
Lebanon Hospital, from Oct. 9, 1914, to 
Feb. 1, 1915, 202 cases, of whom 127 bad 
no scopolamine, and nine had only one in- 
jection. Sixty-six cases (32%) had two or 
more doses. It will be interesting to pause 
for a moment and see why so large a num- 
ber were not treated by this method, when 
we were all so anxious to form an opinion 
based on as many cases as possible. Of 
the 127 cases that had no treatment, sixty- 
four were delivered less than three hours 
after admission, eight received antalgesine, 
six though admitted were not in labor, and 
twelve showed complications. The com- 
plications were eclampsia in two cases, pre- 
maturity in six cases, acute hydramnios, 
vomiting of pregnancy, pyelitis, failed for- 
ceps before admission, each one case. That 
the remaining thirty- seven cases did not 
receive scopolamine was due to the fact 
that the men on the house staff who had 
this work in charge were too busy with 



136 TWILIGHT SLEEP 

other duties to give the patients the neces- 
sary close attention. These figures clearly 
show that though the number not receiving 
this treatment can be reduced when we are 
able to increase the number of internes or 
build more institutions where Twilight 
Sleep can be properly administered, there 
will always remain a considerable percen- 
tage of cases that, because of rapid deliv- 
ery, or not presenting themselves in time, 
will be deprived of the advantages scopo- 
lamine can give. The best that can be said 
of this is that these are probably the cases 
that need it least. 

It will be interesting to bear in mind that 
the following complications arose among 
the cases not receiving scopolamine and 
morphine, and compare them with the com- 
plications of the Twilight Sleep cases. 
There were sixteen (11.86%) lacerations 
of the perineum, seven (5.145%) postpar- 
tum hemorrhages, none of which was se- 
vere, and none of which required more 



TWILIGHT SLEEP 137 

than uterine massage; there were three 
(2.205%) forceps cases. Once the placenta 
did not come away until more than forty- 
five minutes had elapsed, and one case re- 
quired manual extraction. There were ten 
(7.35%) stillbirths, including, of course, 
the premature infants, and those that were 
dead on arrival. In only five out of the 
eight antalgesine cases was there an oli- 
gopnea. In no instance was there any as- 
phyxia. There was no asphyxia of the 
baby and no oligopnea, except in five of the 
antalgesine cases. 

In the sixty-six scopolamine cases the 
largest number of injections was eighteen. 
This was in an entirely normal delivery, 
and the child breathed spontaneously. 
Thirty-five of the cases were primiparae, 
nineteen were para two, three para three, 
four para four, one para seven, two para 
eight and one para nine. Amnesia was 
complete in forty-five (67.95%) of our six- 
ty-six cases. It was partial in nine 



138 TWILIGHT SLEEP 

(13.59%), and there was no amnesia in 
twelve (18.12%). In the twenty-one cases 
where the amnesia was not complete there 
was marked analgesia in eighteen 
(85.68%), slight analgesia in two (9.52%), 
and only one case seemed in no way bene- 
fited by onr efforts. There was a certain 
amount of restlessness in a few cases, but 
only in two did this become annoying. The 
forceps were applied six times (9.06%), 
three times because of delay of the head 
on the perineum, once for clinical instruc- 
tion, once because the mother was ex- 
tremely restless, and once because the 
fetal heart-beats suddenly rose from 120 
to 170. The perineum was lacerated eleven 
times (16.61%). In two cases there was 
post-partum hemorrhage (3.03%), easily 
controlled by massage. In one case the 
placenta did not come away for forty-five 
minutes and in another for one hour. But 
in no case was manual extraction neces- 
sary. The only other complication seen 



TTTILICiHT SLEEP 139 

in the mother during her entire stay in the 
hospital, was that six complained of severe 
thirst, two of these developing an herpeti- 
forni eruption of the month and throat. 

Our sixty-six labors resulted in sixty- 
seven babies, of whom fifty-six (83.44^) 
breathed spontaneously, eight ( 11.92 : V> 
were born oligopneic. The second of the 
twins came forty-five minutes after the 
first. It was very much asphyxiated, and. 
though temporarily revived, it died the 
next day. There were two (2.98%) still- 
births : one following version, which broke 
the child's neck: the other was a prema- 
ture infant, in whom there were no fetal 
heart sounds, and meconium was coming 
away on admission. One of the oligopneic 
babies had difficulty in nursing for about 
a week, and then did very well. The babies 
did at least as well as the non- scopolamine 
cases, and their mothers recovered more 
rapidly, without the shock of labor, having 
been given the advantages of analgesia and 
amnesia. 



140 TWILIGHT SLEEP 

A Few Specimen Cases 

Mrs. L. W. Primipara, vertex presenta- 
tion, received seven injections; a small 
tear of the perineum required one stitch; 
the baby breathed spontaneously ; placenta 
came away in fifteen minutes. The mother 
did not know of its birth until informed by 
her own mother, who visited her six hours 
later. 

Mrs. I. I. Para one, vertex presenta- 
tion, very noisy on admission, received two 
doses. Twenty minutes after the first in- 
jection she became quiet. She was in the 
hospital only three hours and forty-five 
minutes when the child was born. There 
was no tear. Placenta came away in 
twenty minutes. The baby breathed spon- 
taneously. There was no amnesia but 
marked analgesia. 

Mrs. S. R. Para two, vertex presenta- 
tion, received &ve injections. She was 
quiet between the pains, but restless when 



TWILIGHT SLEEP 141 

they occurred. The baby was oligopneic 
for five minutes. The perineum was in- 
tact. She remembered only the first injec- 
tion. She had perfect amnesia, but com- 
plained of a herpes of the throat as a re- 
sult of thirst during labor. 

Mrs. P. Para two, breech presentation, 
received five injections. She was asleep 
between the pains. She did not remember 
being transferred to the operating room 
for final delivery of the after-coming head. 
There was no tear of the perineum. The 
placenta came away in twenty minutes. 

Mrs. G. Para one, vertex presentation, 
received only two injections. She felt the 
child being born, asked for it, but insisted 
that she had no pain. Placenta came away 
in fifteen minutes. 

Mrs. M. Para one, vertex presentation, 
received eighteen injections. She was so 
restless as to make asepsis difficult. Am- 
nesia was perfect. The child breathed 



142 TWILIGHT SLEEP 

spontaneously. The placenta came away 
in fifteen minutes. There was no tear. 

Mrs. A. F. Para nine, vertex presenta- 
tion, received nine injections, sleeping 
most of the time; thirsty when awake. 
She did not know of the birth of the child. 
It breathed spontaneously. There was no 
tear, and the placenta came away in fifteen 
minutes. 

Mrs. R. W. Para one, was so restless 
and tried so hard to get out of bed, and 
was so excitable that she could not be con- 
trolled, so that after two injections the 
treatment had to be discontinued. There 
was no amnesia and no analgesia. 

One patient, whose child had been born 
about midnight, asked the day nurse when 
she came on duty if she would not send for 
the doctor, because the day before she had 
felt life, and now felt none. In other 
words, she was not aware of the birth of 
her child over seven hours after delivery. 

Still another patient, a very successful 



TWILIGHT SLEEP 143 

case, was very much enraged, because she 
had not wanted Twilight Sleep. She and 
the baby left the hospital perfectly well. 
She had given written permission, evi- 
dently without understanding what was to 
be done. This case shows that it is the 
drugs that do the work, and not any par- 
ticular receptive mental attitude of the pa- 
tient. 



IX 



OTHER METHODS OF PAINLESS CHILDBIRTH 

We will consider here only such methods 
of painless childbirth as are now being 
discussed in medical literature. We will, 
therefore, not consider chloroform, ether 
or nitrous oxide in labor, for their rela- 
tive values are now generally accepted. 
Individual doses of opium, or any of its 
derivatives, such as morphine, pantopon, 
or narcophine, used in this manner, though 
frequently of great value in giving relief, 
cannot be considered methods of painless 
childbirth. Hypnosis, chloral, cocaine (lo- 
cal and intraspinous), stovaine, and a host 
of other therapeutic measures, have been 
tried and either discarded, or reserved for 
use in exceptional cases. 

The typical Twilight Sleep is described 
144 



TWILIGHT SLEEP 145 

in the chapter, ' ' The Freiburg Technique. ' ' 
Two variations of it are now being tested 
by the assistants of Kroenig in the wards 
of the Freiburg Frauenklinik. One is sim- 
ply the substitution of narcophine for mor- 
phine. Narcophine is a recent combination 
of morphine with narcotine, held together 
by meconic acid. Meconic acid also exists 
in opium and is inactive. Narcophine rap- 
idly deteriorates and must have some pre- 
servative added to it. It is supposed to 
be less dangerous than morphine, and by 
many believed to be less potent. 

The other method now being tested is 
named after Dr. Siegel, one of Kroenig's 
younger assistants, who is in charge of the 
investigation. Its object is to simplify the 
technique of Twilight Sleep, dispensing 
with the necessity of the most careful 
watching and the use of the memory test, 
by administering definite doses at definite 
times. The treatment is started at about 
the same time as the regular method. The 



146 TWILIGHT SLEEP 



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TWILIGHT SLEEP 147 

injections are given according to the table 
(page 146) devised by Dr. Siegel. 

With the birth of the head he uses a 
small quantity of ethyl-chloride. He has 
administered as many as twenty-seven in- 
jections, and gives primary inertia and 
narrow pelvis as the only contraindica- 
tions to the treatment. In 220 successive 
cases he had 88% complete amnesia, 10% 
partial, and 2% were unaffected. The 
amnesia usually started after the third or 
fourth injection; when the child was born 
prior to this the results were unsatisfac- 
tory. Of the 220 children 67.6% breathed 
spontaneously, 27.7% were oligopneic, 
1.7% apneic; 1.7% were born asphyxiated, 
half of them dying; 1.3% were still-born. 

During the summer of 1914 visitors to 
the clinic, most of whom saw only this 
method, noticed that it occasionally took 
thirty minutes to revive some of the oli- 
gopneic infants. 

In the entire realm of medicine thera- 



148 TWILIGHT SLEEP 

peusis demands individualization, and cer- 
tainly when dealing with such drugs, and 
where the idiosyncrasy may be so pro- 
nounced, a method like the Siegel method 
will often lead to the greatest trouble. 
Twilight cases require the closest care on 
the part of the obstetrician, and the sug- 
gestion that there is a method which could 
be safely left in the hands of an untrained 
assistant is very dangerous. The advice 
to give another dose of scopolamine, or this 
combined with narcophine, just because 
the hands of the clock have moved a cer- 
tain distance, without considering whether 
the fetal heart sounds are what they 
should be, or whether the mother is still 
sufficiently under the influence of the last 
administered dose, seems hardly worthy 
of serious consideration. Surely, wide- 
spread use of the Siegel method would 
soon bring Twilight Sleep into disfavor 
by causing frequent fatalities. 
In 1896, in a discussion of painless child- 



TWILIGHT SLEEP 149 

birth at the Congress of Bussian Physi- 
cians, Savitsky stated that for seventeen 
years he had been using antipyrine per 
rectum. He gave fifteen grains, and some- 
times added from fifteen to twenty drops 
of tincture of opium. When two hours had 
elapsed, the dose was repeated if needed. 
He claims that it is of special value in 
cases of uterine tenesmus, and when the 
os is rigid. The results are seen in from 
fifteen to twenty minutes, and he claims 
never to have had any harmful results. 
The questionnaire which is found in an- 
other chapter brought out the fact that a 
prominent obstetrician in New York al- 
ways used this method with satisfaction. 
No detailed reports exist in the litera- 
ture. 

Dr. M. W. Kapp, of San Jose, Cali- 
fornia, reports excellent results from the 
hypodermic injection of heroin (another 
alkaloid derived from opium) gr. 1/12. 
The effect of one injection, he says, lasts 



150 TWILIGHT SLEEP 

about three hours. When the analgesia 
has worn off he repeats his treatment, 
using 1/24 or 1/36 of a grain. If the pa- 
tient is never under the influence of more 
than gr. 1/12 at one time, the sensory 
nerves are inhibited and the motor nerves 
not affected. He has used it in about 100 
cases, and has seen no harmful results in 
mother or child. He believes that heroin 
rather hastens than retards labor, and 
that it causes no post-partum uterine 
atony. He is convinced that it lessens the 
shock of labor. 

In July, 1914, Prof. Eibemont Des- 
saignes, of the French Academy of Medi- 
cine, reported 112 cases in which he had 
used a drug known as antalgesine obstet- 
rique, recommended to him by the chem- 
ists Paulin and Laurent. This drug is 
supposedly obtained by the action on chlor- 
hydrate of morphine of living ferments re- 
sembling beer leavening, but shows none 
of the characteristics of morphine. When 



TWILIGHT SLEEP 151 

used in labor antalgesine acts on the brain 
and sympathetic centers without notice- 
able effect on the spinal cord. Entire ces- 
sation of pain is effected in a few minutes. 
In eighty-four of his 112 cases there was 
complete analgesia, in twenty-four the an- 
algesia was marked, four patients claimed 
that they had no relief, though their 
screams became less violent. The anal- 
gesia lasts from one-half to twelve hours. 
Sixty-three of his cases needed only one 
injection. In thirty-nine the pain returned 
at the end of five hours, nine received three 
injections, and one case five injections. 
There was one case of post-operative hem- 
orrhage. The third stage averaged thir- 
ty-two minutes. There were no complica- 
tions and the patients were not exhausted. 
These 112 labors resulted in 115 babies, of 
whom seventy-seven cried out at once. 
Twenty-eight seemed dazed and were ap- 
neic, but after a few minutes breathed with 
perfect freedom, and were comparable to 



152 TWILIGHT SLEEP 

Caesarian babies. There was one fetal 
death during labor, the f etns already doing 
poorly at the time of admission to the hos- 
pital. Two babies had convulsions shortly 
after birth, autopsies showing meningeal 
hemorrhage. Three premature children 
died at the end of one, two, and eleven 
days. All the others left the hospital in 
perfect health. 

In the discussion of this paper Pinard, 
of the Beaudelocque, said that his results 
confirmed those of Prof. Dessaignes. They 
advised the use of 1.5 cc. for the first 
dose, and 0.5 cc. for succeeding doses. 
This drug has been variously condemned, 
especially by The Journal of the American 
Medical Association. It is sometimes 
claimed to be nothing more than morphine 
in solution. I have tried it in eight cases, 
and find that it has powerful analgesic 
properties, but it seems to delay the labor. 
Though I have used smaller doses than 
those recommended by the French obstetri- 



TWILIGHT SLEEP 153 

cians, five of the babies were born apneic. 
None of the patients showed any symp- 
toms such as are seen after the administra- 
tion of small or large doses of morphine. 
In a ninth case, where I used a similar bnt 
not identical preparation,* which is recom- 
mended for pre-anesthetic surgical use, the 
patient had a sharp collapse, coming on 
ten or fifteen minutes after the injection. 
The collapse in no way resembled mor- 
phine poisoning. The patient revived in 
about an hour. This drug may not fill the 
needs of painless childbirth, but the last 
word as to its value has not yet been 
heard. 

Weinman, who tried chloroform, aspi- 
rin, sacral anesthesia, and intranasal in- 
jections of cocaine, found them all of only 
moderate value. He then tried pantopon, 
with and without scopolamine. He re- 
ported forty cases, of which twenty-four 

* Antalgesine chirurgical — the morphine supposedly 
not entirely removed. 



154 TWILIGHT SLEEP 

had pantopon alone, eight had one dose of 
pantopon with scopolamine and eight had 
two injections of the combination. The in- 
jection of pantopon consisted of 1 cc. of 
a 2% solution, and showed its effects in 
from fifteen to thirty minutes. In three 
cases, when the pantopon was given too 
late, there was no result. In eight cases 
the analgesia was moderate, and in sixteen 
considerable. In three cases, a second dose 
of pantopon was needed, and gave great 
relief. In five cases, where the pantopon 
was of little value, a second injection was 
given of pantopon and scopolamine, with 
brilliant results. In two cases that re- 
ceived the combination from the start the 
absence of pain was marked. Weinman 
saw no complications in the mother and no 
harm to the child. He concludes that when 
treatment is needed only at the very end 
of labor he prefers "Chloroform a la 
reine," and when required during the en- 
tire labor he prefers pantopon alone, or if 



TWILIGHT SLEEP 155 

the pains are very severe, pantopon with 
scopolamine. 

Jaeger also nsed pantopon instead of 
morphine with scopolamine. He had thirty 
cases, of which only two were not satisfac- 
tory. Von Deschwanden had nine cases 
with this combination. Both of these ob- 
servers fonnd the treatment safe for 
mother and child and valuable in produc- 
ing analgesia. 

None of these methods has as yet been 
sufficiently tried to allow of a definite con- 
clusion as to their value or to warrant their 
general adoption. 



CONCLUSIONS 

The review of the literature and the his- 
tory has shown that we can for convenience 
divide the subject of scopolamine and mor- 
phine in obstetrics into three periods. 
The first or analgesic period, from Stein- 
buchel's original article to Gauss's memor- 
able contribution. During this period the 
experimenters frequently made only one 
injection, and were content with allaying 
a certain amount of pain, in other words, 
producing some analgesia. The second or 
amnesic period starts in 1906, and all ex- 
perimenters during the following years 
considered the work of Freiburg to a 
greater or less extent. Unfortunately they 
did not all follow Gauss 's instructions, and 
therefore did not meet with as satisfactory 
156 



TWILIGHT SLEEP 157 

results as those of Freiburg. These ob- 
servers, too, were frequently satisfied with 
analgesia, but in studying their work we 
see that in general they knew that amnesia 
was most desirable. This period included 
the controversy between Freiburg and 
Berlin. During this time observations 
were made in Germany, Austria, Eussia, 
Poland, Switzerland, France, Great Brit- 
ain, Canada and the United States. The 
third period starts late in the summer of 
1914, and is strictly an American period. 
Freiburg technique is the criterion, but 
for obvious reasons, most of the work is 
being done here. Amnesia is sought, 
either alone or in combination with anal- 
gesia. 

All these observations should help us to 
decide definitely the value of this treat- 
ment as it can be applied in America. The 
natural differences between the larger and 
smaller cities will cause divergence of 
opinion and variation of detail, but when 



158 TWILIGHT SLEEP 

all the experiments are well advanced con- 
clusions can be drawn. This experimental 
stage is not to decide the value of scopolam- 
ine and morphine in obstetrics as applied 
in Freiburg, for if we believe the reports 
from that clinic, and there seems to be no 
reason to doubt them, we cannot but agree 
that for that quiet little town, and with a 
Gauss in continual residence, the method is 
perfect. 

American conditions are different, and 
men of Gauss's caliber are rarely doing 
resident duty, and that, unfortunately, 
must remain one of the main reasons for 
questioning our ability to apply Twilight 
Sleep in America. Here, for the masses, 
the more or less incompetent male or fe- 
male midwife does a large proportion of 
the obstetrics, and this class is hardly fit- 
ted to decide the depth of an amnesic state. 
The man with a large general practice, 
though with considerable obstetrical abil- 
ity, will not have the necessary time to 



TWILIGHT SLEEP 159 

give each individual case. Even the spe- 
cialist will not always have the time to de- 
vote day and night to such work. The 
hope of establishing in every commnnity 
sufficient Twilight hospitals, so that every 
woman can be delivered therein by her own 
physician, and the semi-anesthesia regu- 
lated by a resident expert, is too Utopian 
to be looked for in the near future. Of 
course, if even only a few of these hospi- 
tals were constructed, the number of wo- 
men helped would be considerable. 

Any effort to make all deliveries pain- 
less is at present out of the question. All 
those performing deliveries will not and 
cannot be forced into developing the abil- 
ity and giving the time necessary for this 
work. Furthermore, there is a certain defi- 
nite percentage of cases, especially in mul- 
tiparse, where the entire course of labor 
is too short to allow the drugs to accom- 
plish very much. It must be admitted that 
these women are not, as a rule, those who 



160 TWILIGHT SLEEP 

most need the treatment, but some of them, 
though suffering only a short time, suffer 
tremendously. They will either have to be 
left to their sufferings, or something new 
that acts more quickly will have to be 
found. 

The practicability of continued gas anes- 
thesia, though of undoubted value, at times 
is very limited. It involves all the ex- 
pense of time, plus the not inconsiderable 
cost of gas, and requires two experts in- 
stead of one. My view is that we will 
find after several hundred thousand 
cases have been treated in this country 
that the women of America who feel that 
they need this treatment will be able to 
have it capably given them in every part 
of our land, and that they will no longer 
have to travel to Freiburg to have their 
babies. Many women will feel that their 
nervous energy is well able to stand the 
strain of ordinary labor, and will not want 
to go to the necessary expense of having 



TWILIGHT SLEEP 161 

a trained man devote his entire time to 
them during parturition. The general 
practitioner, though not wishing to give 
sufficient time to the work, will no longer 
denounce the method as dangerous, for its 
safety will have been proven. The special- 
ist in obstetrics will have to add to his 
other armamentarium scopolamine and 
morphine and so arrange his work that he 
can make this sacrifice of time in the inter- 
est of his patient, just as he makes other 
sacrifices daily. 

Finally, we can say that under proper 
surroundings and under proper conditions 
and in properly selected cases this treat- 
ment is ideal. Conducted along the lines 
laid down by Gauss, it is absolutely safe 
for mother and child. 

Until some better and more easily ma- 
nipulated treatment is devised, the tech- 
nique outlined here will be the method of 
choice for alleviating the pains of child- 
birth. 



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CUMULATIVE 
BIBLIOGEAPHY 



This bibliography is complete to June, 
1915. Abstracts of new literature on this 
subject will be supplied by the publisher, 
from time to time, in a form convenient 
for pasting at the end of the present bib- 
liography. 

Those desiring these additional abstracts 
should sign and mail to the publisher the 
card accompanying this book. 

The Author. 



BIBLIOGRAPHY 

Anesthesia — Clinical Congress for Study of, 

under Auspices of Chicago Med. Soc, Jan. 

26-27, 1915. 
Applegate, J. C. — Med. Times, Dec, 1914. 
Aulhorn — Munch, med. Woch., 1910, No. 12. 
Auvard et Lefebre— Btt^. Gen. de Therap., 

Paris, 1888. 
Avarrffy, E. — Gyn. Rundschau (Wien) III, 

Jahrg., No. 8. 
Baer, J. L. — Disc, rep., Jr. A. M. A., April 3, 

1915, p. 1188; May 22, 1915, p. 1723. 
Bandler, S. W. — Med. Record, Jan. 9, 1915; 

Disc. Amer. Jr. Obstet., 1915, p. 339 ; 1915, p. 

155; Amer. Med., Jan. 1915. 
Bardeleben — Zeitsch. f. Geburt. u. Gyn., Bd. 

59, p. 144. 
Bass, 0.— Munch, med. Woch., 1907, No. 11. 
Beach, Ralph M. — Amer. Med., Jan., 1915. 

Disc. Amer. Jr. Obstet, 1914, p. 1026 ; 1915, 

p. 337. Amer. Jr. Obstet., 1915, p. 727. 
Bell, J. N.— Med. Times, Dec, 1914. 
Berger — Aerzt. Vierteljahre Bunds., 1906, Nr. 1. 
177 



178 TWILIGHT SLEEP 

Bernti, J. A.— Med. Klinik, 1909, Nr. 14, p. 497 

and p. 536. 
Bertino, A. — La Ginecologia, Vol. IV, p. 609. 
Bertrand, G. — Presse med., Paris, Dec. 3, 1914. 

Editorial, Jr. A. M. A., Dec. 19, 1914, p. 2233. 
Birchmore — Med. Record, Vol. LXXI, Jan., 

1907, p. 58. 
Blisniansky, G. — Zentr. f. Gyn., 1900. 
Boesch, E.— Zentr. f. Gyn., 1908. 
Boldt, H. J. — Amer. Med., Jan., 1915. Post- 

Grad., Feb., 1915, p. 96. 
Bosse, B., and Eliasberg — Sammlung kUn. 

Vortrdge Gyn., 1909-1911, p. 547. 
Bovee, J. W.—Med. Times, Dec, 1914. 
Brannan, J. W. — Med. Record, May 1, 1915, p. 

715. 
Breitstein, L. J. — Gal. State Jr. Med., June, 

1915. 
Brenizer, A. — Old Dominion Jr. Med. and 

Surg., May 1915. 
Brodhead, G. L. — Amer. Med., Jan., 1915. Post- 

Grad., Feb., 1915, p. 87. Disc. Amer. Jr. 

Obst., 1914, p. 1033. Disc. Amer. Jr. Obst, 

1915, p. 332. 
Brodski, W. A.— Zentr. f. Gyn., 1910. 
Browd, E. K. — Disc. Amer. Jr. Obstet, 1915, pp. 

159, 341. 
Buchanan, T. D.— N. E. Med. Gaz., Vol. L, No. 

4, p. 196. 



BIBLIOGRAPHY 179 

Buist— Brit Med. Jr., 1908. 

Bumm, E. — Grundriss. z. Stud, der Geb., 1914, 

10 Aufl., p. 736. 
Butler — Amer. Jr. Obstet., Aug., 1907, Vol. 

LVI, p. 171. 
Carter, P. J. — New Orleans Med. & Surg. Jr., 

Jan., 1915, No. 7. 
Corbett, D. — Brit. Med. Jr., Apr., 1911, 

p. 868. 
Cotterill, D., and Thomson, H. T. — Edinburgh 

Med. Jr., Dec, 1909. 
Cragin, E. B. — Disc. Amer. Jr. Obstet., 1914, pp. 

1025, 1030. 
Cremer — Monograph. E ntbindung ohne 

Schmerzen, 1906. 
Crile, G. W.— Jr. Am. Med. Ass., Vol. LXI, 

Dec, 1913, p. 2027. Ether Day Address, Mass. 

Gen. Hosp., 1910. Surg. Gyn. and Obstet., 

June, 1915, p. 680. 
Croom, Sir J. H. — Obst. Trans. Edinburgh, Vol. 

XXXIV, 1908-1909. Jr. Obst. & Gyn. Brit. 

Emp., Vol. XVI, p. 16. 
Cushney, Arthur R. — "Pharmacology and 

Therapeutics," 3rd edition, p. 207. 
Dakin, C. E. — Iowa State Med. Soc. Jr., Mar. 5, 

1915. 
Davis, Edward P. — Amer. Jr. of Med. Sciences, 

Jan., 1915, Vol. CXLIX, No. 1. 



180 TWILIGHT SLEEP 

De Lee, J. B.— Med. Times, Dec, 1914. 
Deschwander, v. — K orrespondenzblati 

f. Schiveizer Aerzte, 1911, No. 14. 
Dessaignes, Rebemont — July, 1914, French 

Acad. Med. 
Dickenson, R. L. — Disc, Amer. Jr. Obst., 1915, 

p. 157. 
Deetschy — Korrespondenzblatt f. Schweizer 

Aerzte, 1908, No. 15. 
Dorman, F. A. — Amer. Jr. Obst., 1915, p. 334. 
Drusezn, S. J. — Disc. Am, Jr. Obst., 1915, pp. 

159, 341. N. T. State Med. Jr., Apr., 1915, 

p. 146. 
Fabre et Bourret— Bef. L'Obstet, 1908, p. 394. 
Fehmng, H. — Strassburger med. Zeit., 1909, p. 

14. 
Fonyo, J.— Rev. Zentr. f. Gxjn., 1914, No. 38. 

Budapest i oiv Usjag, 1907. 
Franexxthal and Baer — Clin. Cong, for Study 

of Anesthesia. Chicago, Jan. 26-27, 1915. 
Frigyesi — Abhandlung aus dem Gebiete der 

Gebh. u, Gxjn, Berlin. 1909, Bd. 1, Heft 2. 
Gallant, A. E.— Am. Jr. Obst., 1915, p. 343. 
Gardener, John — Ohio State Journal, April, 

1915. 
Gauss, C. J.— Zentr. f. Gxjn,, 1905. p. 1274. Ar- 

chiv f. Gxjn., 1906, Bd. 78, Heft 3. Med, Klin- 

ik, 1906, Nr. 6. Zentr. f. Gyn., 1907, p. 33, 



BIBLIOGRAPHY 181 

Nr. 2. Med. KUnik, 1909, p. 1722. Karlsruhe 

Address, 1911. Munch, med. Wochensch., 

1907, p. 157. 
Gellhorn, G. — Med. Times, Dec, 1914. 
Geminder — Hegar's Beitr. z. Get. u. Gyn., Bd. 

XII, 1907, p. 299. 
Giuseppi, P. L. — Practitioner, July, 1911. 
Grafenberg, B. D.— Med. Woch., 1910, p. 214, 

No. 36. 
Grandin, E. B..—N. Y. Med. Jr., 1888. 
Halpenny and Vrooman — Amer. Jr. Obst., 

1909, p. 611. 
Harrar — Amer. Jr. Oost., Oct., 1914. Disc. Am. 

Jr. Obst, 1915, p. 335. 
Harrison, V. — Virginia Med. Semi-monthly, 

June 11, 1915. 
Heller, Jacob — Amer. Med., Jan., 1915. Med. 

Record, N. Y., Vol. LXXXVI, 1914. Bull. 

Lying-in Hosp., Feb., 1915. 
Hellman, Alfred M. — Am. Med., Jan., 1915. 

Amer. Jr. Obst., Feb., 1915. Disc. Am. Jr. 

Obst, 1915, pp. 159, 343. Am. Jr. Surgery, 

Jan., 1915. 
Hilkowich — Am. Med., Dec, 1914. 
Hirst, B. C.—Med. Times, Dec, 1914. 
Hoche — Munch, med. Woch., 1907, No. 9. 
Hocheisen — Munch, med. Woch., 1906, Nrs. 37 

and 38; 1907, Nr. 11. 



182 TWILIGHT SLEEP 

Hold— Amer. Jr. of Clin. Med., May, 1907. 
Holden, F. C.-im. Jr. Obst., 1915, p. 338. 
Holmes, R. W.—Am. Jr. Obst, 1915, p. 772. 
Holzbach — Munch, med. Woch., Vol. LIV, 1907, 

p. 1228. 
Humpstone, 0. P. — L. I. Med. Jr., Dec, 1914. 
Iljin, F. M.— Rep. Zentr. f. Gyn., No. 42, p. 

1355. 
Ingraham, C. B. — Colorado Med., Jan., 1915, 

XII, No. 1. a 
Innes, A. — Practitioner, 1912. 
Jacobson, S. D. — Disc. Am. Jr. Obst., 1915, p 

340. 
Jager, 0.— Zentr. f. Gyn., No. 46, 1910, p. 1504 
Johnen, A. — Inaug. Dis., Freiburg, 1911. 
Junor, K. F. — Med. Record, Jan. 23, 1915, p 

146. 
Kaiserling — Monats. f. Geb. u. Gyn., Bd. 28 

p. 255. 
Kronen, H. — Ther. d. Gegenwart, Nr. 1, Bd. 1 
Klein — Aerzt. Vierteljahre Rundschau, 1906 

No. 1. 
Kleinertz, F. — Zentr. f. Gyn., No. 42, 1908, p 

1387. 
Knipe, W. H. — Modern Hospital, Jan., 1915 

Amer. Med., Jan., 1915. Amer. Jr. Obst., Dec. 

1914. Med. Times, Dec, 1914. 
Kosmak, G. W.— Disc Am. Jr. Obst., 1915, p. 

343. 



BIBLIOGBAPHY 183 

Kromer — Bef. Munch, med. Woch., 1909, p. 763. 
Kroenig, Prof. B. — Vortrdge u. practische 

Therapie, II. Serie, Heft 10, 1908, p. 773. 

Deutsch. med. Woch., XXXIY, 1908, No. 23. 

Brit. Med. Jr., II, 1908. 
Laurendeau — Presse med., 1905. 
Lazard — South. Cal. Tract., 1915, XXX, pp. 

13-22. 
Leavitt, F. — Amer. Jr. Clin. Med., Apr., 1915. 
Leedham, Charles Green — Brit. Med. Jr., 1909, 

p. 962. 
Lehman, O. — Zeitschr. f. Geb. u. Gyn., Bd. 58, 

1906, Heft 2. Deut. med. Woch., 1905. 
Libby, W. E.— Jr. A. M. A., May 22, 1915, p. 

1728. 
Lieb, C— Disc. Am, Jr. Obst., 1914, p. 1031. 
Link — Psych, neurol. Woch., 1905, No. 26. 
Long, Constance — Brit. Med. Jr., 1913. 
Lynch, F. W.— Chic. Med. Bee, March, 1915. 
McDuffie, M. W. — N. A. Jr. Homeopathy, 1915, 

Vol. XXX, No. 1. 
McLean, M.-im. Jr. Obst., 1915, p. 341. 
McPherson — Am. Jr. Obst., Oct., 1914. Disc. 

Am. Jr. Obst., 1915, p. 335. Bull. Lying-in 

Hosp., Feb., 1915. 
Mann, A. — Illinois Med. Jr., Apr., 1915. 
Mannsfeld — Wien klin. Woch., 1908, XXI, 

No. 1. Archiv f. Gyn., Bd. 81, Heft 2. 



184 TWILIGHT SLEEP 

Matwjejew, G. Th. — Rev. Zentr. f. Gyn., 1908, 

p. 779. 
Mayer, K.— Zentr. f. Gyn., 1908, p. 779. 
Moshee, G. C. — Jr. of Kansas Med. Soc, 1914, 

Vol. XIV, No. 12. Surg. Gyn. & Obst., Vol. 

XX, No. 3, 1915, p. 348. 
Muller — Monatshefte f. Gyn. u. Geo., 1906, 

Heft 5. 
Nejelow and Skulta — Report in Zentr. f. Gyn., 

No. 42, p. 1355. 
Newell, Franklin S. — Trans. Am. Gyn. Soc., 

1907. Surg. Gyn, & Obst., July, 1906. 
Pinnard — Disc. Fr. Acad. Med., July, 1914. 
Pisarzewski — Polnische Monats. f. Geb. & Gyn., 

1905, Heft 4. 
Ploeger — Zeitsch. f. Geb. u. Gyn., Bd. 53, Heft 

2. 
Polak, John — L. I. Med. Jr., Dec., 1914. N. 

Y. Med. Jr., Feb. 13, 1915. N. Y. Med. Times, 

Vol. XLII, 1914, p. 361. Disc. Am. Jr. Obst, 

1915, p. 337. 
Preller — Munch, med. Woch., 1907, No. 4, p. 

161. 
Price, N. G. — Jr. Med. Soc. New Jersey, Jan., 

1915, p. 21. 
Pushnig— Wien klin. Woch., 1905 Nr. 16. 
Raining — FrommeVs Jahresber., 1904. 
Ratnofp, N.— N. Y. State Med. Jr., Apr., 1915, 

p. 146. 



BIBLIOGRAPHY 185 

Rongy and Arluck — N. Y. Med. Jr., Dec, 1914. 
Rongy, A. J. — Amer. Med., Jan., 1915. Amer. 

Jr. Obst., Oct., 1914. N. Y. State Med. Soc, 

Apr. 28, 1915. 
Salzberger, Max — Inaug. Dis., Freiburg, 1910. 
Sandow, B. F. — Cal. State Jr. Med., June, 1915. 
Savitzey — Rev. Brit. Med. Jr., July, 1896. 

Vratch, 1896. 
Scadron, Samuel J. — Interstate Jr. Med., Vol. 

XXI, No. 1. 
Schloessingk, K. — Med. Times, Dec., 1914. 

Med. Record, Apr. 10, 1915. 
Schneiderlein — Munch, med. Woch., 1903. 
Shaw, E. R.— " Physiological Study of Twilight 

Sleep,' ' 1915. 
Shears, G. P.— Disc. Am. Jr. Obst, 1915, p. 157. 
Sheill, Spencer — Jr. Obst. & Gyn. Brit. Emp., 

Vol. XVII, p. 146. 
Sick, P. — German Med. Weekly, 1910. 
Siegel, P. W. — Munch, med. Woch., 1913, No. 

41. Bent. med. Woch., 1914, No. 21. 
Slawyk, Gertrude — Inaug. Dis., Freiburg, 

1912. 
Smith, Alfred — Jr. Obst. & Gyn. Brit. Emp., 

1908, p. 147. 
Smith, J. T. — Cleveland Med. Jr., Jan., 1915. 
Solomons, B. A. H., and Freeland, J. R. — Brit. 

Med. Jr., Jan., 1911. 



186 TWILIGHT SLEEP 

Soehrt — Inaug. Dis. Dorpat, 1886. 
Stefpens— Arch. f. Gyn., Vol. LXXXI, 1907, 

No. 2. 
Steinbuchel, von — Zentr. f. Gyn., 1902, No. 

48. Beitr. z. Geb. u. Gyn., Chrobak's Festsch., 

1903. 
Strassman — Berlin klin. Woch., June, 1911. 
Straub, Walter — Munch, med. Woch., 1913, 

No. 4. 
Tate, M. A.— Lancet Clinic, Oct. 24, 1914. 
Thompson, H. T.—Edin. Med. Jr., 1909. 
Tichauer, Wilhelm — Inaug. Dis., Freiburg, 

1911. 
Toth— Bef. Zentr. f. Gyn., 1909, p. 665. 
Trabscha — Report Zentr. f. Gyn., No. 42, p. 

1355. 
Van Hoosen, B. — "Scop. Morph. Anesthesia," 

Chicago, 1915. 
Viet— Therap. Monat., 1908, XXII. 
Viron and Morel — Progres medical, 1906, No. 

7. 
Waldo, Ralph — Amer. Med., Jan., 1915. 
Wainright, John W. — Amer. Med., Jan., 1915. 
Wakefield, Francis B. — Am. Jr. Obst., Mar., 

1915, p. 422. Med. Bee, 1915, LXXXVII, p. 

289. 
Wartapetian — Inaug. Dis., Jena, 1904. Rev. 

Zentr. f. Gyn., 1905, No. 49. 



BIBLIOGRAPHY 187 

Weinbrenner — Disc. Med. Gesel, z. Magdeburg. 

Report Munch, med. Woch., 1906, No. 29. 
Weingarten — Inaug. Dis., Giessen, 1904. Rev. 

Zentr. f. Gyn., 1905, No. 51. 
Weinmann — Miinch. med. Woch., Dec, 1911. 
Whitney, F. W. — Amer. Med., Feb., 1915. 
Williams, H. S.— " Painless Childbirth/ ' N. Y., 

1914; " Twilight Sleep," N. Y, 1914. 
Zipper — Monats. /. Geb. u. Gyn., May, 1905, p. 

20. 
Zdstker, E. G. — Med. Times, Dec, 1914. 



188 ADDITIONAL BIBLIOGBAPHY 



ADDITIONAL BIBLIOGKAPHY 189 



190 ADDITIONAL BIBLIOGEAPHY 



INDEX 



America, Twilight Sleep 
in, 104; Applegate, Bell, 
Bovee, Gelhorn and 
Zinker believe field lim- 
ited, 113; Baer, J. L., 
condemns method, 117; 
Beach compares 1,000 
cases with 1,000 non- 
drug cases, 113; Birch- 
more produces analgesia, 
10 5; Brodhead and 
Stein use Siegel meth- 
od, 110; Dakin, C. E., 
discards treatment, 116; 
disadvantages compared 
with Germany, 106; fif- 
ty answers to thirteen 
questions, 119; Franken- 
thal and Baer on, 111; 
Gardiner favors in se- 
lected cases, 116; N. G. 
Green reports twenty 
cases, 115; Harrar and 
McPherson 's success in 
100 cases, 108; Hilko- 
wich approves of meth- 
od, 109; Humpstone on, 
108; increasing interest 
and growing literature, 
105; Knipe enthusiastic, 
108; Leavitt uses mor- 
phine, hyo seine and cac- 
tine tablets, 114; Libby 
asserts method has not 
reached perfection, 118; 
McPherson abandons 
method after short trial, 



104 ; Newell abandons 
method after 123 cases, 
104; Polak favorably 
disposed, 108 ; Eongy 's 
conclusions, 107 ; Scad- 
ron reports 202 cases, 
112; spartein added to 
other drugs by Whitney, 
110; symposium in 
American Medicine, 
109 ; Wakefield con- 
vinced of method's 
value, 111 

Amnesia, dosage governed 
by depth of, 35; Gauss' 
discussion of, 35; Gauss 
induces, 29; value of in 
labor, 32 

Applegate thinks field lim- 
ited, 113 

Arluck and Eongy report 
100 eases, 106 

Aschoff, ref., 81 

Avarrffy did not follow 
Gauss 's technique, re- 
sults unsatisfactory, 62 

Baer, J. L., vigorously con- 
demns treatment, 117 

Bass considers method use- 
ful, reporting 107 cases, 
58 

Beach, favorable compari- 
son of 1,000 cases by, 
113 

Bell, says method has lim- 
ited field, 113 



191 



192 



INDEX 



Berger reports results very 
satisfactory, 64 

Bertino disapproves after 
400 cases, 22 

Bibliography, 162 

Birchmore successful in 
producing analgesia, 105 

Bosse and Eliasberg re- 
port 122 successful cases, 
64 

Bovee believes field limit- 
ed, 113 

Brodsky reports 200 cases, 
102 

Bruti reports high percent- 
age of successful cases 
at Freiburg, 46 

Buist reports favorably on 
scopolamine, 93 

Bumm comments on use of 
scopolamine, 84 

Butler reports on scopol- 
amine in surgery, 104 

Carter, Philip J., reviews 
literature, 112 

Case reports with statis- 
tics, 133; Lebanon hos- 
pital cases, 135 

Chemistry and pharmacol- 
ogy* &■ S. Pharmaco- 
poeia on scopolamine, 86 ; 
chemical formula of, 
88; effects on pupil, 
heart and brain, 88; 
large doses may cause 
cacosia, 90 ; L i e b ' s 
claims as to effect on 
mother's milk, 91; man- 
nit a preservative for, 
91; results of overdos- 
age, 89; Gertrude Sla- 
wyk on, 89; test of pur- 
ity, 88 



Child, effects of scopolam- 
ine labor on, 42 
Childbirth, other methods 
of painless, 144; heroin 
injections by Kapp, 149; 
injections of antalgesine 
obstetrique by Dessaig- 
nes, 150; Jaeger substi- 
tutes pantopon for mor- 
phine with scopolamine, 
155; need of individual- 
ization, 14 7; Pinard 
confirms Dessaignes' re- 
ports, 152 ; Savitsky 's 
system, 149 ; S i e g e 1 
method, 145 ; substitu- 
tion of narcophine for 
morphine, 14 5; von 
Deschwanden uses pan- 
topon with scopolamine, 
155; Weinman uses pan- 
topon with scopolamine, 
153 

Complications in scopolam- 
ine labors discussed by 
Gauss, 38 

Conclusions from review- 
ing literature, 156; all 
deliveries cannot be 
made painless, 15 9; 
faulty American condi- 
tions, 158; future of the 
system, 160; the three 
periods of scopolamine 
and morphine in labor, 
156 

Corbett reports favorably 
on Twilight Sleep, 95 

Cotterill on drug injection 
in surgical operations, 
95 

Cremer considers treatment 
harmless, 21; first to 
recommend scopolamine 



INDEX 



193 



and morphine in private 
practice, 21 ; scopolam- 
ine and morphine in 
eclampsia, 22 

Crile on causation of 
shock, 128 

Croom, conclusions of, as 
to value of scopolamine, 
95 

Dakin, C. E., discards 
treatment, 116 

DeLee declares drugs have 
inherent dangers, 113 

Dessaignes, Prof. Bibe- 
mont, uses antalgesine 
obstetrique in labor, 150 

Dietschy finds method sat- 
isfactory, 62 

Eclampsia, scopolamine and 
morphine in, 22 

England, Twilight Sleep 
in, 93; Buist reports fa- 
vorably, 93; conclusions 
of Corbett, 94; Con- 
stance Long records suc- 
cess, 101; Croom 's con- 
clusions, 95 ; Giuseppi, 
lengthy report by, 97; 
Hatfield and Ferguson 
use drugs satisfactorily, 
96; Prof. Albert Smith 
reports complete anal- 
gesia, 102; Solomon and 
Freeland, report on, 100 ; 
Spencer Shill finds satis- 
faction in, 101 

Fabre and Bourret favor- 
ably impressed, 60 

Fehling fails to follow 
Freiburg technique, is 
not impressed, 64 



Frankenthal and Baer re- 
port thirty-nine cases, 
111 

Freiburg-Berlin controver- 
sy, 78; Bumm quoted, 
84; effects of Hocheisen 
and Steff en 's reports, 
83; Gauss answers crit- 
ics, 79; Gauss explains 
Hocheisen 's failure, 80; 
Gauss's 1,000 cases, 80; 
Hocheisen replies t o 
Gauss, 82; Steffen sup- 
ports Hocheisen as 
against Gauss, 82 

Freiburg technique, 66 ; ab- 
sence of muscular coor- 
dination, 70; care of 
newborn child, 74; dis- 
position of patient, 66; 
1 ' islands of memory, ' ' 
70; memory test, 68; oc- 
casional herpetic erup- 
tion, 76 ; preparation 
for, 66; primary inertia 
a contraindication, 67; 
pupillary reaction, 71 ; 
restlessness an unpleas- 
ant complication, 72 ; 
second stage of labor, 
71 

Frigyesi, overdose of mor- 
phine a real objection, 
63; reports 200 cases, 
63 

Gardiner favors system in 
properly selected cases, 
116 

Gauss adopts Steinbuchel 
treatment, 22 ; average 
duration of scopolamine 
labor, 40; care in pre- 
paring solution, 28 ; 



194 



INDEX 



comparison of milk se- 
cretion in drug and 
non-drug eases, 41; com- 
plications found by, 38; 
conclusions of, 46; con- 
vinced of value of meth- 
od after 6,000 cases, 65; 
describes drug's action, 
29 ; discusses amnesia, 
35; early technique of, 
23; effects of drug-con- 
trolled labor on child, 
42; experiences of, with 
500 cases, 24; finds 
comparison in effect on 
child in favor of Twi- 
light Sleep, 44; governs 
dosage by depth of am- 
nesia, 35; names treat- 
ment ' l Dammerschlaf , ' ' 
23 ; operative frequence 
of 12.6%, 39; placenta 
expulsion without help, 
40 ; produces amnesia, 
30; reports 300 cases, 
23; second report of, 
24 ; standardizes tech- 
nique, 23; table of com- 
plications in 500 cases, 
26; useful reactions, 35 

Gellhorn thinks method 
has limited field, 113 

Geminder, reporting 100 
cases, could not recom- 
mend treatment, 59 

Giuseppi reports at length 
on Twilight Sleep, 99 

Green, N. G., reports twen- 
ty cases, 115 

Halpern and Brooman re- 
port 100 cases, 102 

Harrar and McPherson, 
success in 100 cases, 108 



Hilkowich approves o f 
method, 109 

Hocheisen disapproves of 
scopolamine, 47 ; dis- 
putes Gauss 's theories, 
82; fails to follow Frei- 
burg method, 49; table 
of cases in Bumm's clin- 
ic, 50 

Hohn, Eeichardt and, dis- 
cover scopolamine, 87 

Hold reports satisfactory 
results, 64 

Hump stone asserts that 
method requires hospital 
facilities, 109 

' ' Islands of memory, ' ' 
37, 70 

Iljin has success with six- 
ty-seven cases, 102 

Jaeger substitutes panto- 
pon for morphine, 155 

Kapp, M. W., uses heroin 
for painless childbirth, 
149 

Klein reports satisfactory 
results, 64 

Kleinerts believes system 
should be confined to 
hospital practice, 61; 
reports 280 cases, 
60 

Knipe enthusiastic in fa- 
vor of method, 108 

Korff, ref., 13 

Kroenig, Prof., ref., 65 

Labor, average duration of 

scopolamine, 40 
Laurendeau, experience of 

in fifteen cases, 20 



INDEX 



195 



Leavitt successfully uses 
morphine, hyoscine and 
cactine tablets, 114 

Lebanon Hospital cases, 
with statistics, 135 

Lehmann concludes meth- 
od is safe and valuable, 
53 ; reports seventy 
cases, 52; seeks anal- 
gesia, 52 

Libby, W. E., declares 
method not yet perfect, 
118 

Lieb asserts scopolamine 
remains in mother 's 
milk, 91 

Light and noise as disturb- 
ing elements, 36 

Long, Constance, reports 
successful use of scop- 
olamine, 101 

Mannit, a preservative for 
scopolamine, 91 

Mansfield decries anal- 
gesia, 58 

Matwjejew found suffer- 
ing relieved, 60 

Mayer follows Gauss 's 
technique, 62 ; thinks 
method should be used 
only in institutions, 62 

McPherson abandons meth- 
od after short trial, 104 

Memory test as reaction, 
35 

Milk secretion, drug and 
non-drug 1 peases com- 
pared, 41 

Morphine and scopolamine, 
von Steinbuchel o n, 
Cent. f. Gyn., 13 

Mosher writes on Twilight 
Sleep, 111 



Miiller obtains analgesia 
and drowsiness, 21 

Muscular coordination as 
reaction, 35 

Narcophine, substitution of 
for morphine, 145 

Nejelow reports sixty 
cases, 102 

Newell abandons Twilight 
Sleep after 123 cases, 
104 

Noise and light as disturb- 
ing elements, 36 

Painless childbirth, other 
methods of, 144 

Pinard confirms Dessaig- 
nes's reports on antal- 
gesine obstetrique, 152 

Pisarzewsky, results in 
three cases, 20 

Placenta expulsion with- 
out help, 40 

Ploefer, operative fre- 
quence reported by, 40 

Polak concludes method is 
a first-stage procedure, 
110; favorably disposed 
to Twilight Sleep, 108 

Preller adopts Gauss 's 
technique, 54 ; believes 
system justified if used 
with care, 56; summary 
of 120 cases, 54 

Pushnig, results in sixty- 
two cases, 19 

Pupil, sensibility of as re- 
action, 35 

Earning continues Warta- 
petian 's investigations, 
17 



196 



INDEX 



Eeichardt and Hohn dis- 
cover scopolamine, 87 

Rongy, conclusions of, aft- 
er twenty-five cases, 107 ; 
reports, 116 

Savitsky's system of pain- 
less childbirth, 149 

Scadron reports 202 cases, 
112 

Schlimpert, study of con- 
tractions by, 38 

Schneiderlein, ref., 13 

'Scopolamine, advantages 
summed up by Gauss, 
46 ; chemical formula, 
88; chemistry and phar- 
macology of, 86; dis- 
covered by Eeichardt 
and Hohn, 87; effects on 
pupil, heart and brain, 
88; excreted by kid- 
neys, 89; history of in 
obstetrics, 13 

Shill, Spencer, finds satis- 
faction in use of scopo- 
lamine, 101 

Siegel method of Twilight 
Sleep, 145; primary in- 
ertia and narrow pelvis 
only contra-indications, 
146; table of injections, 
146 

Slawyk, Gertrude, on chem- 
istry and pharmacology 
of scopolamine, 89 

Smith, Prof. Albert, re- 
ports complete analgesia, 
102 

Solomons and Freeland re- 
port on Twilight Sleep, 
100 

Spinal reflex as indicator 
of drug action, 36 



Steffen could not recom- 
mend scopolamine in pri- 
vate practice, 58; disre- 
gards Gauss's technique, 
57; does not favor sco- 
polamine, 57; report of 
300 cases, 56; supports 
Hocheisen in controver- 
sy with Gauss, 81 

Steinbuchel, von, basic 
principles of, 14 ; first re- 
port on scopolamine and 
morphine, 14; first uses 
scopolamine and mor- 
phine in obstetrics, 13 

Straub discovers a scopo- 
lamine preservative in 
mannit, 91 

Theoretical considerations 
of Twilight Sleep, 128; 
conclusions, 131 ; Crile 
on shock causation, 128; 
fear as an unfavorable 
factor in labor, 130; 
value of Crile 's theory, 
129 

Trabseha reports forty 
cases, 102 

Von Deschwanden uses 
pantopon with scopolam- 
ine, 155 

Wakefield convinced of 
method's value, 111 

Wartapetian reports on 
use of scopolamine and 
morphine, 16 

Weingarten reports forty- 
five cases, 18; succeeds 
with only one injection, 
18 



INDEX 197 



Weinman uses pantopon Ziffer reports thirty-one 

and scopolamine, 153 cases, 18; uses same dos- 

Whitney, F. W., adds spar- age as Weingarten, 18 

tein to other drugs sue- Zinker believes field limit- 

cessfuUy, 110 ed, 113 



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SENATOR and KAMINER— Marriage and Disease. Being an 
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SMITH — Some Common Remedies, and Their Use in Practice. 

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SQUEER and BUGBEE— Manual of Cystoscopy. By J. Bently 
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STARK— The Growth and Development of the Baby. A tabular 
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Heavy paper, 20 by 25 inches 50c net. 

STEPHENSON— Eye-Strain in Every-day Practice. By Sidney 
Stephenson, M.B., CM. Edin., D.O. Oxon, F.R.C.S. Edin. 
Ophthalmic Surgeon to the Queen's Hospital for Children; 
Editor of the Ophthalmoscope. 
8vo, Cloth, x + 139 pages $1.50 net. 

STEPHENSON— A Review of Hormone Therapy. 1913. 

8vo, Cloth, viii-f 170 pages $1.00 net. 

Bound and interleaved edition of the famous "Hormone 
Number" of the "Prescriber" (Edinburgh). 

SWIETOCHOWSKI — Mechano-Therapeutics in General Prac- 
tice. By G. de Swietochowski, M.D., M.R.C.S. Fellow of 
the Royal Society of Medicine; Clinical Assistant, Electrical 
and Massage Department King's College Hosp. 
i2mo, Cloth, xiv+141 pp., 31 Illustrations $1.50 net. 

TURNER and PORTER— The Skiagraphy of the Accessory 
Nasal Sinuses. By A. Logan Turner, M.D., F.R.C.S.E., 
F.R.S.E. Surgeon to the Ear and Throat Department, the 
Royal Infirmary, Edinburgh, and W. G. Porter, M.B., B.Sc, 
F.R.CS.E. Surgeon to the Eye and Throat Infirmary, 
Edinburgh. 
Quarto, Cloth, 45 pages of text. 39 plates $4.50 net. 

8 



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WANKLYN — How to Diagnose Smallpox. A Guide for General 
Practitioners, Post-Graduate Students, and Others. By W. 
McC. Wanklyn, B.A. Cantab., M.R.C.S., L.R.C.P., D.P.H. 
Assistant Medical Officer of the London County Council and 
formerly Medical Superintendent of the River Ambulance 
Service (Small-pox). 
8vo, Cloth, 102 pages. Illustrated $1.50 net. 

WATSON — Gonorrhoea and its Complications in the Male and 
Female. By David Watson, M.B., CM., Surgeon Glasgow 
Lock Hospital Dispensary, Surgeon for Venereal Diseases 
Glasgow Royal Infirmary, etc., etc. 

8vo, Cloth, 375 pages, 72 illustrations, 12 plates, some col- 
ored $3.75 net. 

WHITE— The Pathology of Growth. Tumours. By Charles 
Powell White, M.C., F.R.C.S. Director, Pilkington Cancer 
Research Fund, Pathologist Christie Hospital, Special Lec- 
turer in Pathology, University of Manchester. 8vo, Cloth, 
xvi+235 pages. Illustrated $3.50 net. 

WHITE — Occupational Affections of the Skin. A brief account of 
the trade Processes and Agents which give rise to them. By 
P. Prosser White, M.D., Ed., M.R.C.S. Lond. Life Vice- 
President, Senior Physician and Dermatologist, Royal Albert 
Edward Infirmary, Wigan, Vice-President, Assoc. Certif. 
Fact. Surgeon; Life Fellow, Lond. Dermat. Society; etc., etc. 
8vo, Cloth, 165 pages $2.00 net. 

WICKHAM and DEGRAIS— Radium. As employed in the 
treatment of Cancer, Angiomata, Keloids, Local Tuberculosis 
and other affections. By Louis Wickham, M.V.O. Medecin 
de St. Lazare; Ex-Chef de Clinique a L'Hopital St. Louis, and 
Paul Degrais, Ex-Chef de Laboratoire a L'Hopital St. Louis. 
Chefs de service au Laboratoire Biologique du Radium; Lau- 
reats de L'Academie de Medecine. 
8vo, Cloth, 53 illustrations, viii+m pages $1.25 net. 

WRENCH— The Healthy Marriage. A Medical and Psycho- 
logical Guide for Wives. By G. T. Wrench, M.D., B.S. Lond., 
Past Assistant Master of the Rotunda Hospital, Dublin. 
8vo, Cloth, x+300 pages $1.50 net. 

WRIGHT— The Unexpurgated Case against Woman Suffrage. 
By Sir Almroth E. Wright, M.D., F.R.S. 
8vo, Cloth, xii + 188 pages $1.00 net. 

WRIGHT — On Pharmaco-Therapy and Preventive Inoculation; 
Applied to Pneumonia in the African Native with a discourse 
on the Logical Methods which ought to be Employed in the 
Evaluation of Therapeutic Agents. By Sir Almroth E. 
Wright, M.D., F.R.S. 
8vo, Cloth, 124 pages $2.00 net. 

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9 



